Provider Demographics
NPI:1770613275
Name:COSTELLO, KELLIE COLLEEN (MOTRL)
Entity type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:COLLEEN
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10791 S 72ND ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PAPILLION
Mailing Address - State:NE
Mailing Address - Zip Code:68046-3423
Mailing Address - Country:US
Mailing Address - Phone:402-932-2782
Mailing Address - Fax:402-932-2705
Practice Address - Street 1:10601 S 72ND ST STE 103
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046-3408
Practice Address - Country:US
Practice Address - Phone:402-932-2782
Practice Address - Fax:402-932-2705
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1405225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO31535024OtherBLUE CROSS BLUE SHIELD