Provider Demographics
NPI:1871256453
Name:MICHELLE A COSTELLO LCSW, PLLC
Entity Type:Organization
Organization Name:MICHELLE A COSTELLO LCSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ALYSE
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:312-593-3553
Mailing Address - Street 1:615 HINMAN AVE APT 3D
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3047
Mailing Address - Country:US
Mailing Address - Phone:312-593-3553
Mailing Address - Fax:
Practice Address - Street 1:5215 N RAVENSWOOD AVE STE 214
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1670
Practice Address - Country:US
Practice Address - Phone:312-476-9722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-20
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)