Provider Demographics
NPI:1376569723
Name:COSTELLO, PATRICIA A (MSW, LMHP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MSW, LMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 PIONEERS BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68502-5963
Mailing Address - Country:US
Mailing Address - Phone:402-489-9959
Mailing Address - Fax:402-489-2219
Practice Address - Street 1:3201 PIONEERS BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-5963
Practice Address - Country:US
Practice Address - Phone:402-489-9959
Practice Address - Fax:402-489-2219
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE85613OtherBLUE CROSS BLUE SHIELD
NE232826OtherMIDLANDS CHOICE
NE80003614126Medicaid