Provider Demographics
NPI:1255605242
Name:COSTILOW, ANN M (MSW)
Entity type:Individual
Prefix:MS
First Name:ANN
Middle Name:M
Last Name:COSTILOW
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:M
Other - Last Name:COSTILOW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW
Mailing Address - Street 1:2626 CHARLES DR
Mailing Address - Street 2:
Mailing Address - City:CHALMETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70043-3779
Mailing Address - Country:US
Mailing Address - Phone:504-278-4006
Mailing Address - Fax:
Practice Address - Street 1:2626 CHARLES DR
Practice Address - Street 2:
Practice Address - City:CHALMETTE
Practice Address - State:LA
Practice Address - Zip Code:70043-3779
Practice Address - Country:US
Practice Address - Phone:504-278-4006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
LA11051101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018214Medicaid