Provider Demographics
NPI:1467787101
Name:DANA M. COSTELLO, PEDIATRIC PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:DANA M. COSTELLO, PEDIATRIC PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-204-3491
Mailing Address - Street 1:501 JULIE CT
Mailing Address - Street 2:
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-1100
Mailing Address - Country:US
Mailing Address - Phone:973-204-3491
Mailing Address - Fax:201-891-1344
Practice Address - Street 1:501 JULIE CT
Practice Address - Street 2:
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-1100
Practice Address - Country:US
Practice Address - Phone:973-204-3491
Practice Address - Fax:201-891-1344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-14
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00907700208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty