Provider Demographics
NPI:1891331732
Name:COSTELLO, JOHN R (CASAC-T)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 PAGE PARK DR
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-7500
Mailing Address - Country:US
Mailing Address - Phone:845-486-2950
Mailing Address - Fax:
Practice Address - Street 1:41 PAGE PARK DR
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-7500
Practice Address - Country:US
Practice Address - Phone:845-486-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)