Provider Demographics
NPI:1639398639
Name:COSTELLO, LINDA KRYSIAK (PT)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:KRYSIAK
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 HOME LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-1181
Mailing Address - Country:US
Mailing Address - Phone:248-852-3527
Mailing Address - Fax:
Practice Address - Street 1:5839 W MAPLE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-2278
Practice Address - Country:US
Practice Address - Phone:248-851-6999
Practice Address - Fax:248-851-6898
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002503225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist