Provider Demographics
NPI:1184831604
Name:COSTELLO, DANETTE (LMP)
Entity Type:Individual
Prefix:
First Name:DANETTE
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20307 VIKING AVE NW STE 102
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-8321
Mailing Address - Country:US
Mailing Address - Phone:360-697-3737
Mailing Address - Fax:360-779-6337
Practice Address - Street 1:20307 VIKING AVE NW STE 102
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-8321
Practice Address - Country:US
Practice Address - Phone:360-697-3737
Practice Address - Fax:360-779-6337
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00010900225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist