Provider Demographics
NPI:1497159412
Name:COSTELLO, KELLY (LCSW-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 HOWARD RD
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-4720
Mailing Address - Country:US
Mailing Address - Phone:443-695-3692
Mailing Address - Fax:
Practice Address - Street 1:1714 JARRETTSVILLE RD
Practice Address - Street 2:
Practice Address - City:JARRETTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21084-1524
Practice Address - Country:US
Practice Address - Phone:443-695-3692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15818101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health