Provider Demographics
NPI:1558161331
Name:COSTELLO, LAUREL (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:KATE
Other - Last Name:SIMONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8 WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04021-3634
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 ROCK ROW STE 320
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4877
Practice Address - Country:US
Practice Address - Phone:207-303-3300
Practice Address - Fax:207-250-2139
Is Sole Proprietor?:No
Enumeration Date:2025-03-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1690133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered