Provider Demographics
NPI:1346360393
Name:COSTELLO, CHRISTINE T (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:T
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:CHRISTINE
Other - Middle Name:T
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:708 CHURCH ST
Mailing Address - Street 2:SUITE 219
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3875
Mailing Address - Country:US
Mailing Address - Phone:847-864-6266
Mailing Address - Fax:847-864-9633
Practice Address - Street 1:708 CHURCH ST
Practice Address - Street 2:SUITE 219
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3875
Practice Address - Country:US
Practice Address - Phone:847-864-6266
Practice Address - Fax:847-864-9633
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent