Provider Demographics
NPI:1881701860
Name:COSTELLO, RAYMOND M (PHD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:M
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 MEMORIAL BLVD
Mailing Address - Street 2:SOUTH TEXAS VETERANS HEALTH CARE SYSTEM
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028
Mailing Address - Country:US
Mailing Address - Phone:830-370-6769
Mailing Address - Fax:830-792-2474
Practice Address - Street 1:3600 MEMORIAL BLVD
Practice Address - Street 2:SOUTH TEXAS VETERANS HEALTH CARE SYSTEM
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028
Practice Address - Country:US
Practice Address - Phone:830-370-6769
Practice Address - Fax:830-792-2474
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-0916103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114314103Medicaid
TX114314103Medicaid