Provider Demographics
NPI:1851859656
Name:COSTELLO, SHAWNA ROSE (LMT)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:ROSE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 S 211TH PL UNIT C8
Mailing Address - Street 2:
Mailing Address - City:SEATAC
Mailing Address - State:WA
Mailing Address - Zip Code:98198-5163
Mailing Address - Country:US
Mailing Address - Phone:206-919-5362
Mailing Address - Fax:
Practice Address - Street 1:19987 1ST AVE S STE 103
Practice Address - Street 2:
Practice Address - City:NORMANDY PARK
Practice Address - State:WA
Practice Address - Zip Code:98148-2400
Practice Address - Country:US
Practice Address - Phone:206-824-7200
Practice Address - Fax:206-832-4652
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60926517225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist