Provider Demographics
NPI:1316475163
Name:COSTELLO, DESIREE ELIZABETH
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:ELIZABETH
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:ELIZABETH
Other - Last Name:MEANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4250 LOUISE DR
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89706-0607
Mailing Address - Country:US
Mailing Address - Phone:775-530-5133
Mailing Address - Fax:
Practice Address - Street 1:4250 LOUISE DR
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89706-0607
Practice Address - Country:US
Practice Address - Phone:775-530-5133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNVMT2829225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist