Provider Demographics
NPI:1487426243
Name:COSTELLO, TATYAHNA CAYANE
Entity type:Individual
Prefix:
First Name:TATYAHNA
Middle Name:CAYANE
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 1:2216 S NORWOOD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-3413
Mailing Address - Country:US
Mailing Address - Phone:562-673-8959
Mailing Address - Fax:
Practice Address - Street 1:658 ROGERS AVE APT 2R
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-1565
Practice Address - Country:US
Practice Address - Phone:562-673-8959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1203101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical