Provider Demographics
NPI:1356976120
Name:COSTLY, RACHAEL SHANNEL
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:SHANNEL
Last Name:COSTLY
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 1:6811 LAUGHLIN DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77489-3412
Mailing Address - Country:US
Mailing Address - Phone:225-788-7048
Mailing Address - Fax:832-787-1218
Practice Address - Street 1:9500 COUNTY ROAD 190
Practice Address - Street 2:
Practice Address - City:MANVEL
Practice Address - State:TX
Practice Address - Zip Code:77578-5078
Practice Address - Country:US
Practice Address - Phone:225-788-7048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82-5309384Medicaid