Provider Demographics
NPI:1700173549
Name:COSTELLO, DAWN M (LMT)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:M
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 ELA RD
Mailing Address - Street 2:STE. 105
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-2385
Mailing Address - Country:US
Mailing Address - Phone:847-550-1115
Mailing Address - Fax:
Practice Address - Street 1:765 ELA RD
Practice Address - Street 2:STE. 105
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-2385
Practice Address - Country:US
Practice Address - Phone:847-550-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227012961225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist