Provider Demographics
NPI:1639843659
Name:COSTELLO, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 FRICOT CITY RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANDREAS
Mailing Address - State:CA
Mailing Address - Zip Code:95249-9642
Mailing Address - Country:US
Mailing Address - Phone:209-736-4500
Mailing Address - Fax:
Practice Address - Street 1:10400 FRICOT CITY RD
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249-9642
Practice Address - Country:US
Practice Address - Phone:209-736-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 171M00000X, 172V00000X
CAAMFT144592106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker