Provider Demographics
NPI:1962581959
Name:COSTELLO, SUSAN (MA LMHC)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MA LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 RUSSETT HILL RD
Mailing Address - Street 2:
Mailing Address - City:SHERBORN
Mailing Address - State:MA
Mailing Address - Zip Code:01770-1225
Mailing Address - Country:US
Mailing Address - Phone:508-545-1955
Mailing Address - Fax:508-545-1480
Practice Address - Street 1:17 RUSSETT HILL RD
Practice Address - Street 2:
Practice Address - City:SHERBORN
Practice Address - State:MA
Practice Address - Zip Code:01770-1225
Practice Address - Country:US
Practice Address - Phone:508-545-1955
Practice Address - Fax:508-545-1480
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALMHC 282101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALM0301OtherBLUE CROSS BLUE SHIELD