Provider Demographics
NPI:1851438196
Name:COSTELLO, VESNA C (OTR-L)
Entity Type:Individual
Prefix:MS
First Name:VESNA
Middle Name:C
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:OTR-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 BLUEGRASS TRAIL
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:VA
Mailing Address - Zip Code:24128
Mailing Address - Country:US
Mailing Address - Phone:540-961-1230
Mailing Address - Fax:540-951-0613
Practice Address - Street 1:2727 ELECTRIC RD
Practice Address - Street 2:SUITE 104
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3547
Practice Address - Country:US
Practice Address - Phone:540-961-1230
Practice Address - Fax:540-951-0613
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119004260225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7413822OtherAETNA