Provider Demographics
NPI:1700195773
Name:COSTELLO, MEGAN ABBOTT (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:ABBOTT
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 WASHOUGAL RIVER RD
Mailing Address - Street 2:
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671-1507
Mailing Address - Country:US
Mailing Address - Phone:503-307-9743
Mailing Address - Fax:
Practice Address - Street 1:845 WASHOUGAL RIVER RD
Practice Address - Street 2:
Practice Address - City:WASHOUGAL
Practice Address - State:WA
Practice Address - Zip Code:98671-1507
Practice Address - Country:US
Practice Address - Phone:503-307-9743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60014238235Z00000X
OR012790235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist