Provider Demographics
NPI:1417295130
Name:COSTELLO, THERESA MARY (PHD, PT)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:MARY
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PHD, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 CROMPTON RD
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980-2306
Mailing Address - Country:US
Mailing Address - Phone:919-605-1799
Mailing Address - Fax:
Practice Address - Street 1:83 CROSS ROAD LN
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2331
Practice Address - Country:US
Practice Address - Phone:540-885-8424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206885225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist