Provider Demographics
NPI:1659986453
Name:COSTELLO, KRISTIN ALLIE (LMT)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ALLIE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 MAPLE WAY S
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3911
Mailing Address - Country:US
Mailing Address - Phone:262-894-3100
Mailing Address - Fax:
Practice Address - Street 1:S31W24757 W SUNSET DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189-7014
Practice Address - Country:US
Practice Address - Phone:262-547-2250
Practice Address - Fax:262-547-2775
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12922-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist