Provider Demographics
NPI:1023723210
Name:SMITH COSTELLO, KELLY MAE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MAE
Last Name:SMITH COSTELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 MONITOR ST
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-3534
Mailing Address - Country:US
Mailing Address - Phone:509-300-1221
Mailing Address - Fax:
Practice Address - Street 1:1230 MONITOR ST
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-3534
Practice Address - Country:US
Practice Address - Phone:509-300-1221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61581254101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health