Provider Demographics
NPI:1326212143
Name:COSTERELLA, MARY ANNE LISA (MA, LADC)
Entity Type:Individual
Prefix:MS
First Name:MARY ANNE
Middle Name:LISA
Last Name:COSTERELLA
Suffix:
Gender:F
Credentials:MA, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 NATIONAL DR
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4371
Mailing Address - Country:US
Mailing Address - Phone:860-657-8910
Mailing Address - Fax:
Practice Address - Street 1:110 NATIONAL DR
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4371
Practice Address - Country:US
Practice Address - Phone:860-657-8910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT#000527101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)