Provider Demographics
NPI:1780737379
Name:COSTELLO, RALPH WILLIAM (MFT)
Entity type:Individual
Prefix:MR
First Name:RALPH
Middle Name:WILLIAM
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 FASHION LANE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780
Mailing Address - Country:US
Mailing Address - Phone:714-669-9120
Mailing Address - Fax:714-669-9120
Practice Address - Street 1:161 FASHION LANE
Practice Address - Street 2:SUITE 205
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780
Practice Address - Country:US
Practice Address - Phone:714-669-9120
Practice Address - Fax:714-669-9120
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist