Provider Demographics
NPI:1952966368
Name:COSTELLO, AMBER PAULINE (OTD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:AMBER
Middle Name:PAULINE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5251 PATTON RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-7178
Mailing Address - Country:US
Mailing Address - Phone:217-827-6169
Mailing Address - Fax:
Practice Address - Street 1:6347 ST PETERS CHURCH RD
Practice Address - Street 2:
Practice Address - City:CONOVER
Practice Address - State:NC
Practice Address - Zip Code:28613-8862
Practice Address - Country:US
Practice Address - Phone:704-608-6449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8154225XM0800X, 225X00000X
8154225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation