Provider Demographics
NPI:1194177949
Name:COSTELLO, KELLY LYNN (BCBA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4103 LESTER CT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1121
Mailing Address - Country:US
Mailing Address - Phone:615-335-5844
Mailing Address - Fax:
Practice Address - Street 1:4103 LESTER CT
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1121
Practice Address - Country:US
Practice Address - Phone:615-335-5844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-15-19490103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst