Provider Demographics
NPI:1124150750
Name:COSTELLO, ANGELA (LMFT)
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 SAN VICENTE BLVD STE 520
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5455
Mailing Address - Country:US
Mailing Address - Phone:310-877-0657
Mailing Address - Fax:
Practice Address - Street 1:6330 SAN VICENTE BLVD STE 520
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5455
Practice Address - Country:US
Practice Address - Phone:310-887-0657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2023-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53654106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist