Provider Demographics
NPI:1386889145
Name:THE COSTELLO CENTER
Entity type:Organization
Organization Name:THE COSTELLO CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:E
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LMHC
Authorized Official - Phone:727-345-2667
Mailing Address - Street 1:8081 38TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-1029
Mailing Address - Country:US
Mailing Address - Phone:727-345-2667
Mailing Address - Fax:727-209-2667
Practice Address - Street 1:8081 38TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1029
Practice Address - Country:US
Practice Address - Phone:727-345-2667
Practice Address - Fax:727-209-2667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7394101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty