Provider Demographics
NPI:1699447177
Name:COSTELLO, KRISTIN MICHELLE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:MICHELLE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 STEVERS MILL RD
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-1240
Mailing Address - Country:US
Mailing Address - Phone:215-385-0207
Mailing Address - Fax:
Practice Address - Street 1:129 STEVERS MILL RD
Practice Address - Street 2:
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-1240
Practice Address - Country:US
Practice Address - Phone:215-385-0207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-02
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC009905225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist