Provider Demographics
NPI:1285760421
Name:COSTELLO, CHRISTOPHER KEVIN (PT, DPT, SCS, CSCS)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:KEVIN
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:PT, DPT, SCS, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:333 EARLE OVINGTON BLVD
Mailing Address - Street 2:SUITE 225
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-3610
Mailing Address - Country:US
Mailing Address - Phone:516-321-2424
Mailing Address - Fax:516-321-2424
Practice Address - Street 1:127 WEST 30TH STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-4001
Practice Address - Country:US
Practice Address - Phone:212-967-5838
Practice Address - Fax:212-967-5786
Is Sole Proprietor?:No
Enumeration Date:2007-02-24
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA35392225100000X
NY028277225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ4WFH1Medicare PIN