Provider Demographics
NPI:1215439302
Name:COSTELLO, VINCENT THOMAS JR (MSW, LISW)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:THOMAS
Last Name:COSTELLO
Suffix:JR
Gender:M
Credentials:MSW, LISW
Other - Prefix:MR
Other - First Name:VINCENT
Other - Middle Name:THOMAS
Other - Last Name:COSTELLO
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LISW
Mailing Address - Street 1:1251 NILLES RD STE 5
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-7205
Mailing Address - Country:US
Mailing Address - Phone:513-939-0300
Mailing Address - Fax:513-939-0310
Practice Address - Street 1:1251 NILLES RD STE 5
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-7205
Practice Address - Country:US
Practice Address - Phone:513-939-0300
Practice Address - Fax:513-939-0310
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1.0001132104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker