Provider Demographics
NPI:1730901802
Name:COSTELLO, KAITLYN R
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:R
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 1:4 DALEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-1510
Mailing Address - Country:US
Mailing Address - Phone:631-275-7104
Mailing Address - Fax:
Practice Address - Street 1:4 DALEWOOD PL
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-1510
Practice Address - Country:US
Practice Address - Phone:631-275-7104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program