Provider Demographics
NPI:1992321624
Name:KOSTELLO, TRAVIS
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:
Last Name:KOSTELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6251 NW 63RD ST APT 1403
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64151-3382
Mailing Address - Country:US
Mailing Address - Phone:636-399-0015
Mailing Address - Fax:
Practice Address - Street 1:9411 N OAK TRFY STE 200
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64155-2262
Practice Address - Country:US
Practice Address - Phone:816-436-6383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020016059225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist