Provider Demographics
NPI:1639389448
Name:COSTELLO, KELLY E (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:E
Last Name:COSTELLO
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SULLIVAN PKWY
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-3929
Mailing Address - Country:US
Mailing Address - Phone:978-735-5361
Mailing Address - Fax:
Practice Address - Street 1:5 SULLIVAN PKWY
Practice Address - Street 2:
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-3929
Practice Address - Country:US
Practice Address - Phone:978-735-5361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2199181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical