Provider Demographics
NPI:1215987201
Name:COSTELLA, SHANNON BROOK (MSPT, CERT MDT)
Entity type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:BROOK
Last Name:COSTELLA
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Gender:F
Credentials:MSPT, CERT MDT
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Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:630-928-5040
Practice Address - Street 1:2307 LAPORTE AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-6996
Practice Address - Country:US
Practice Address - Phone:219-477-4500
Practice Address - Fax:219-477-4567
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2017-04-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN05007003A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist