Provider Demographics
NPI:1164854220
Name:COSTELLO, MARGARET ANN (MA, JD, LLP)
Entity Type:Individual
Prefix:PROF
First Name:MARGARET
Middle Name:ANN
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MA, JD, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15601 ESSEX AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1720
Mailing Address - Country:US
Mailing Address - Phone:313-596-9854
Mailing Address - Fax:313-596-9825
Practice Address - Street 1:17177 NORTH LAUREL PARK; SUITE 131
Practice Address - Street 2:CRUZ CLINIC
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152
Practice Address - Country:US
Practice Address - Phone:734-462-3210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002741103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist