Provider Demographics
NPI:1609339670
Name:COSTIN, COLLEEN MARIE (PSYD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
Last Name:COSTIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28594 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-7103
Mailing Address - Country:US
Mailing Address - Phone:630-859-6800
Mailing Address - Fax:
Practice Address - Street 1:2500 W FABYAN PKWY
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-1572
Practice Address - Country:US
Practice Address - Phone:630-879-2110
Practice Address - Fax:630-762-4727
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.010581103G00000X, 103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist