Provider Demographics
NPI:1396251641
Name:COSTELLO, CARLY ERIN (MSW)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:ERIN
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:COSTELLO
Other - Last Name:GLOVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:207 D ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-3103
Mailing Address - Country:US
Mailing Address - Phone:304-887-2994
Mailing Address - Fax:
Practice Address - Street 1:207 D ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-3103
Practice Address - Country:US
Practice Address - Phone:304-887-2994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-22
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009452001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical