Provider Demographics
NPI:1073300679
Name:COSTELLO, MCKENZIE ANNE
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:ANNE
Last Name:COSTELLO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-1604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8371 S UPHAM WAY APT 207
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80128-6374
Practice Address - Country:US
Practice Address - Phone:720-292-0656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician