Provider Demographics
NPI:1952320434
Name:COSTANZO, MARY LOU (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOU
Last Name:COSTANZO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 ELLSWORTH RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2706
Mailing Address - Country:US
Mailing Address - Phone:860-523-0288
Mailing Address - Fax:
Practice Address - Street 1:968 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2172
Practice Address - Country:US
Practice Address - Phone:860-523-0288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0008451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT14000CT86503OtherBLUE CROSS/BLUESHIELD OF
CT14000CT86503OtherBLUE CROSS/BLUESHIELD OF