Provider Demographics
NPI:1124354212
Name:COSTELLO, PATRICIA JEWELL (BS)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:JEWELL
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:JEWELL
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BS
Mailing Address - Street 1:4669 FARNHAM ST.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1308
Mailing Address - Country:US
Mailing Address - Phone:858-380-4669
Mailing Address - Fax:
Practice Address - Street 1:9445 FARNHAM ST.
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1308
Practice Address - Country:US
Practice Address - Phone:858-380-4669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-23
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
N/A171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator