Provider Demographics
NPI:1487048666
Name:COSTELLO, JOHANNA
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 PONTIAC ST APT 8
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-2477
Mailing Address - Country:US
Mailing Address - Phone:330-322-5302
Mailing Address - Fax:
Practice Address - Street 1:17 PONTIAC ST APT 8
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-2477
Practice Address - Country:US
Practice Address - Phone:330-322-5302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9003225200000X
OH01440225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant