Provider Demographics
NPI:1700199015
Name:COSTELLO, ANN P (LCSW)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:P
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 MAINE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3906
Mailing Address - Country:US
Mailing Address - Phone:207-653-7200
Mailing Address - Fax:
Practice Address - Street 1:25 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4869
Practice Address - Country:US
Practice Address - Phone:207-653-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC94941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical