Provider Demographics
NPI:1407210636
Name:COSTELLO, EMIR
Entity Type:Individual
Prefix:
First Name:EMIR
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20101 HAMILTON AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-1306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20101 HAMILTON AVE STE 160
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-1306
Practice Address - Country:US
Practice Address - Phone:310-217-8177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-13
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAAMFT116407106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator