Provider Demographics
NPI:1215208277
Name:COSTELLO, CORTNEY ANN (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:CORTNEY
Middle Name:ANN
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-8698
Mailing Address - Country:US
Mailing Address - Phone:417-689-0661
Mailing Address - Fax:
Practice Address - Street 1:1525 E REPUBLIC RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6527
Practice Address - Country:US
Practice Address - Phone:417-831-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-24
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD7204101YP2500X
MO2012004105101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional