Provider Demographics
NPI:1497346654
Name:COSTELLO, VINCENT NORMAN JR (LSW)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:NORMAN
Last Name:COSTELLO
Suffix:JR
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8080 OLD YORK ROAD
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027
Mailing Address - Country:US
Mailing Address - Phone:267-626-2018
Mailing Address - Fax:
Practice Address - Street 1:8080 OLD YORK ROAD
Practice Address - Street 2:
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027
Practice Address - Country:US
Practice Address - Phone:267-626-2018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-31
Last Update Date:2021-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW137001104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker