Provider Demographics
NPI:1922729219
Name:COSTELLO, MARY KATHRYN (DPT)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:KATHRYN
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15118 TRAIL CREEK PL
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-1944
Mailing Address - Country:US
Mailing Address - Phone:941-284-0963
Mailing Address - Fax:
Practice Address - Street 1:2595 TAMPA RD STE V&W
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3152
Practice Address - Country:US
Practice Address - Phone:727-712-1567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT38096225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist