Provider Demographics
NPI:1972663052
Name:COSTELLO, STEPHANIE B (MSW, LCSW, CEAP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:B
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MSW, LCSW, CEAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2755 NW CROSSING DR
Mailing Address - Street 2:STE 210
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-7050
Mailing Address - Country:US
Mailing Address - Phone:215-917-0032
Mailing Address - Fax:458-206-4897
Practice Address - Street 1:2755 NW CROSSING DR
Practice Address - Street 2:STE 210
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7050
Practice Address - Country:US
Practice Address - Phone:215-917-0032
Practice Address - Fax:458-206-4897
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR53971041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1972663052OtherNPI