Provider Demographics
NPI:1326151382
Name:COSTELLO, SCOTT L (MSW LCSW)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:L
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20855 S LAGRANGE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-2042
Mailing Address - Country:US
Mailing Address - Phone:815-806-9300
Mailing Address - Fax:815-806-3076
Practice Address - Street 1:20855 S LAGRANGE RD STE 202
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-2042
Practice Address - Country:US
Practice Address - Phone:815-806-9300
Practice Address - Fax:815-806-3076
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0093461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203336Medicare ID - Type UnspecifiedMEDICARE ID