Provider Demographics
NPI:1215127352
Name:COSTELLO, MARCIA A (LIC AC)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:A
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 PAQUIN DR
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-1317
Mailing Address - Country:US
Mailing Address - Phone:508-786-0788
Mailing Address - Fax:
Practice Address - Street 1:530 BOSTON POST RD E
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-3645
Practice Address - Country:US
Practice Address - Phone:508-786-0788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA202824171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist