Provider Demographics
NPI:1437630662
Name:COSTELLO, DOLORES (MSW)
Entity Type:Individual
Prefix:MS
First Name:DOLORES
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 WALWORTH ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-2936
Mailing Address - Country:US
Mailing Address - Phone:617-835-5329
Mailing Address - Fax:
Practice Address - Street 1:655 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-3158
Practice Address - Country:US
Practice Address - Phone:617-835-5329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-25
Last Update Date:2018-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA105432-SW-LICSW1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA105432-SW-LICSWOtherCOMMONWEALTH OF MASSACHUSETTS
MA105432-SW-LICSWMedicaid