Provider Demographics
NPI:1598999302
Name:COSTELLO, SANDY ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:SANDY
Middle Name:ELIZABETH
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SANDY
Other - Middle Name:ELIZABETH
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, ED
Mailing Address - Street 1:2841 THOUSAND ACRES RD
Mailing Address - Street 2:
Mailing Address - City:DELANSON
Mailing Address - State:NY
Mailing Address - Zip Code:12053-1917
Mailing Address - Country:US
Mailing Address - Phone:518-875-6724
Mailing Address - Fax:
Practice Address - Street 1:2841 THOUSAND ACRES RD
Practice Address - Street 2:
Practice Address - City:DELANSON
Practice Address - State:NY
Practice Address - Zip Code:12053-1917
Practice Address - Country:US
Practice Address - Phone:518-875-6724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY561975051174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist