Provider Demographics
NPI:1184828956
Name:COSTELLO, MAE CECILE (LAC)
Entity Type:Individual
Prefix:
First Name:MAE
Middle Name:CECILE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2143 NE BROADWAY ST STE 107C
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1512
Mailing Address - Country:US
Mailing Address - Phone:503-309-3963
Mailing Address - Fax:
Practice Address - Street 1:2143 NE BROADWAY ST STE 107C
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1512
Practice Address - Country:US
Practice Address - Phone:503-309-3963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00936171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist