Provider Demographics
NPI:1285078519
Name:COSTELLO, MACK S (BCBA)
Entity type:Individual
Prefix:MR
First Name:MACK
Middle Name:S
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3502 OAKLAND DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-2861
Mailing Address - Country:US
Mailing Address - Phone:352-328-1349
Mailing Address - Fax:
Practice Address - Street 1:3502 OAKLAND DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-2861
Practice Address - Country:US
Practice Address - Phone:352-328-1349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst