Provider Demographics
NPI:1376853895
Name:COSTELLO, COLLEEN
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 BRONSON RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219
Mailing Address - Country:US
Mailing Address - Phone:315-278-6932
Mailing Address - Fax:
Practice Address - Street 1:5590 BEAR RD
Practice Address - Street 2:
Practice Address - City:N SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-1649
Practice Address - Country:US
Practice Address - Phone:315-218-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005982235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist