Provider Demographics
NPI:1811688492
Name:COSTELLO, EMILY (DACM, MACOM, LAC)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:DACM, MACOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11495 SW GREENBURG RD APT B
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5319
Mailing Address - Country:US
Mailing Address - Phone:315-209-0983
Mailing Address - Fax:
Practice Address - Street 1:11775 SW GREENBURG RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6445
Practice Address - Country:US
Practice Address - Phone:503-381-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist