Provider Demographics
NPI:1457982811
Name:COSTELLO, ELIZABETH CHRISTINE (COTA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CHRISTINE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 OWEN POINT RD
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-2520
Mailing Address - Country:US
Mailing Address - Phone:314-315-0880
Mailing Address - Fax:
Practice Address - Street 1:1720 VIETH DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2056
Practice Address - Country:US
Practice Address - Phone:573-635-6193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013021532224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant