Provider Demographics
NPI:1699788992
Name:COSTELLO, PATRICK (MSW,LCSW)
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:MSW,LCSW
Other - Prefix:
Other - First Name:T
Other - Middle Name:PATRICK
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW,LCSW,
Mailing Address - Street 1:9911 ARABIAN DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709
Mailing Address - Country:US
Mailing Address - Phone:208-362-5622
Mailing Address - Fax:
Practice Address - Street 1:9911 ARABIAN DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709
Practice Address - Country:US
Practice Address - Phone:208-870-6460
Practice Address - Fax:208-395-1948
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW4741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical