Provider Demographics
NPI:1790245355
Name:COSTELLO, CARELIS (MS)
Entity Type:Individual
Prefix:
First Name:CARELIS
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6284 COUNTRY FAIR CIR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-2822
Mailing Address - Country:US
Mailing Address - Phone:561-207-0148
Mailing Address - Fax:
Practice Address - Street 1:1639 FORUM PL STE 7
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2330
Practice Address - Country:US
Practice Address - Phone:561-712-8821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health