Provider Demographics
NPI:1295756013
Name:COSTELLO, JOAN (PHD)
Entity type:Individual
Prefix:DR
First Name:JOAN
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 SKOKIE BLVD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2851
Mailing Address - Country:US
Mailing Address - Phone:847-291-0151
Mailing Address - Fax:847-291-0151
Practice Address - Street 1:601 SKOKIE BLVD
Practice Address - Street 2:SUITE 305
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2851
Practice Address - Country:US
Practice Address - Phone:847-291-0151
Practice Address - Fax:847-291-0151
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL705050Medicare ID - Type UnspecifiedMEDICARE PSYCOLOGIST