Provider Demographics
NPI:1568038917
Name:COSTELLO, THERESA A (PT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:A
Other - Last Name:WHISKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16 MAYBROOK RD STE L
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL HALL
Mailing Address - State:NY
Mailing Address - Zip Code:10916-2741
Mailing Address - Country:US
Mailing Address - Phone:845-636-4344
Mailing Address - Fax:845-636-4355
Practice Address - Street 1:745 STATE ROUTE 17M STE 104
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-2663
Practice Address - Country:US
Practice Address - Phone:845-782-3200
Practice Address - Fax:845-782-3100
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist