Provider Demographics
NPI:1982028643
Name:COSTELLO, MATT (EDS)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2317 CASS RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-3111
Mailing Address - Country:US
Mailing Address - Phone:419-381-2391
Mailing Address - Fax:419-381-2388
Practice Address - Street 1:2317 CASS RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-3111
Practice Address - Country:US
Practice Address - Phone:419-381-2391
Practice Address - Fax:419-381-2388
Is Sole Proprietor?:No
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3077263103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool