Provider Demographics
NPI:1609911312
Name:COSTELLO, REBECCA JEAN (DT, PTA)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:JEAN
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:DT, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4935 CROSSBILL RD
Mailing Address - Street 2:
Mailing Address - City:TAMAROA
Mailing Address - State:IL
Mailing Address - Zip Code:62888-2224
Mailing Address - Country:US
Mailing Address - Phone:618-357-3635
Mailing Address - Fax:618-357-2002
Practice Address - Street 1:4935 CROSSBILL RD
Practice Address - Street 2:
Practice Address - City:TAMAROA
Practice Address - State:IL
Practice Address - Zip Code:62888-2224
Practice Address - Country:US
Practice Address - Phone:618-357-3635
Practice Address - Fax:618-357-2002
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant