Provider Demographics
NPI:1437419371
Name:COSTELLO, KATHLEEN M (PSYD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:KATEY
Other - Middle Name:M
Other - Last Name:FELDMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14953 S VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-5804
Mailing Address - Country:US
Mailing Address - Phone:815-609-1544
Mailing Address - Fax:815-609-1670
Practice Address - Street 1:14953 S VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-5804
Practice Address - Country:US
Practice Address - Phone:815-609-1544
Practice Address - Fax:815-609-1670
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007889103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical