Provider Demographics
NPI:1205178167
Name:COSTELLO, CARISSA ANN (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:CARISSA
Middle Name:ANN
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:MRS
Other - First Name:CARISSA
Other - Middle Name:ANN
Other - Last Name:SLOKOVITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:100 CARMAN AVE
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1160
Mailing Address - Country:US
Mailing Address - Phone:516-572-3953
Mailing Address - Fax:
Practice Address - Street 1:100 CARMAN AVE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1160
Practice Address - Country:US
Practice Address - Phone:516-572-3953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-19
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005335-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health