Provider Demographics
NPI:1982117776
Name:COSTELLO, ELISSA (LCSW)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:
Other - Last Name:PINETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:134 STATE ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-3293
Mailing Address - Country:US
Mailing Address - Phone:203-237-2229
Mailing Address - Fax:203-686-1677
Practice Address - Street 1:134 STATE ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-3293
Practice Address - Country:US
Practice Address - Phone:203-237-2229
Practice Address - Fax:203-686-1677
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT100101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical