Provider Demographics
NPI:1568605673
Name:COSTELLO, MARY ANGELA (BS, SW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANGELA
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:BS, SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16200 19 MILE RD
Mailing Address - Street 2:P.O BOX380710
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1103
Mailing Address - Country:US
Mailing Address - Phone:248-276-6000
Mailing Address - Fax:
Practice Address - Street 1:16200 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1103
Practice Address - Country:US
Practice Address - Phone:248-276-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802059032104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker