Provider Demographics
NPI:1578163598
Name:COSTELLO, JOSEPH ANTHONY III
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ANTHONY
Last Name:COSTELLO
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 E COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-8925
Mailing Address - Country:US
Mailing Address - Phone:734-625-6100
Mailing Address - Fax:
Practice Address - Street 1:100 N STAEBLER RD STE A-B
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-9755
Practice Address - Country:US
Practice Address - Phone:652-273-4252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician