Provider Demographics
NPI:1720257173
Name:THOMAS-COSTELLO, MARY ABIGAIL (LAC, LMT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ABIGAIL
Last Name:THOMAS-COSTELLO
Suffix:
Gender:F
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 386
Mailing Address - Street 2:19 EAST MAIN STREET
Mailing Address - City:TRUMANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14886-0386
Mailing Address - Country:US
Mailing Address - Phone:607-274-7520
Mailing Address - Fax:607-274-7520
Practice Address - Street 1:19 E. MAIN STREET
Practice Address - Street 2:
Practice Address - City:TRUMANSBURG
Practice Address - State:NY
Practice Address - Zip Code:14886
Practice Address - Country:US
Practice Address - Phone:607-274-7520
Practice Address - Fax:607-274-7520
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25003352171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist