Provider Demographics
NPI:1902230618
Name:COSTELLO, MARIO
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4510 DRESSLER RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2546
Mailing Address - Country:US
Mailing Address - Phone:330-494-5155
Mailing Address - Fax:330-494-6868
Practice Address - Street 1:2795 FRONT ST
Practice Address - Street 2:SUITE A
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-1900
Practice Address - Country:US
Practice Address - Phone:330-945-7100
Practice Address - Fax:330-945-4305
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1300466-TRNE101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH10024Medicaid