Provider Demographics
NPI:1326198136
Name:COSTELLO, WILLIAM H (PHD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:H
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 CRYSTAL STREET
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880
Mailing Address - Country:US
Mailing Address - Phone:781-224-3374
Mailing Address - Fax:
Practice Address - Street 1:14 CRYSTAL STREET
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880
Practice Address - Country:US
Practice Address - Phone:781-224-3374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1778103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical