Provider Demographics
NPI:1306926233
Name:COSTELLO, KIM K (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:K
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 CANTERBURY PL E
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-8105
Mailing Address - Country:US
Mailing Address - Phone:601-825-5678
Mailing Address - Fax:
Practice Address - Street 1:4500 I-55 NORTH
Practice Address - Street 2:SUITE 291, HIGHLAND VILLAGE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211
Practice Address - Country:US
Practice Address - Phone:601-362-0859
Practice Address - Fax:601-362-0870
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSSO780235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist