Provider Demographics
NPI:1275007767
Name:COSTELLO, MICHELLE ALYSE (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ALYSE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 HINMAN AVE APT 3D
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3047
Mailing Address - Country:US
Mailing Address - Phone:312-593-3553
Mailing Address - Fax:
Practice Address - Street 1:5215 N RAVENSWOOD AVE STE 214
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1670
Practice Address - Country:US
Practice Address - Phone:312-476-9722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0206721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical