Provider Demographics
NPI:1720171051
Name:COSTELLO, SUSAN J (MA, LPC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:J
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 DODIE DR
Mailing Address - Street 2:
Mailing Address - City:PARSIPPANY
Mailing Address - State:NJ
Mailing Address - Zip Code:07054-1750
Mailing Address - Country:US
Mailing Address - Phone:973-889-9094
Mailing Address - Fax:
Practice Address - Street 1:155 COUNTY RD
Practice Address - Street 2:
Practice Address - City:CRESSKILL
Practice Address - State:NJ
Practice Address - Zip Code:07626-2200
Practice Address - Country:US
Practice Address - Phone:201-227-1211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00186600101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ314011Medicare UPIN