Provider Demographics
NPI:1972861748
Name:COSTELLE, GARY (PT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:COSTELLE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950243
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0243
Mailing Address - Country:US
Mailing Address - Phone:502-253-1035
Mailing Address - Fax:502-253-1037
Practice Address - Street 1:2400 EASTPOINT PKWY
Practice Address - Street 2:STE 120
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-4154
Practice Address - Country:US
Practice Address - Phone:502-253-6689
Practice Address - Fax:502-253-6680
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY001753225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist