Provider Demographics
NPI:1730141433
Name:COSTELLO, THERESA (PHD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LEE RD
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:MA
Mailing Address - Zip Code:02067-1716
Mailing Address - Country:US
Mailing Address - Phone:508-415-6607
Mailing Address - Fax:
Practice Address - Street 1:407 EAST AVE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-5299
Practice Address - Country:US
Practice Address - Phone:401-725-6160
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00747103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RITC42754Medicaid