Provider Demographics
NPI:1265586572
Name:COSTELLO, KENNETH PATRICK
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:PATRICK
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:KEN
Other - Middle Name:P
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MPT
Mailing Address - Street 1:600 OAKMONT LN
Mailing Address - Street 2:STE 600C
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:630-575-7450
Practice Address - Street 1:2937 S BRENTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:MO
Practice Address - Zip Code:63144
Practice Address - Country:US
Practice Address - Phone:314-961-3804
Practice Address - Fax:314-961-1147
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002005830225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist