Provider Demographics
NPI:1407599418
Name:COSTIS, PAMELA (LCSW)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:COSTIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BRANDYWINE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-9311
Mailing Address - Country:US
Mailing Address - Phone:847-404-0528
Mailing Address - Fax:
Practice Address - Street 1:3000 DUNDEE RD STE 101
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2424
Practice Address - Country:US
Practice Address - Phone:847-400-0078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0214721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical