Provider Demographics
NPI:1114751047
Name:COSTELLO, MARY KAY
Entity type:Individual
Prefix:MS
First Name:MARY KAY
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:EMMI
Other - Middle Name:
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1715 W GRANVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1114
Mailing Address - Country:US
Mailing Address - Phone:847-971-0259
Mailing Address - Fax:
Practice Address - Street 1:10000 DEE RD
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1565
Practice Address - Country:US
Practice Address - Phone:847-493-8685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-02
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist