MEDICARE: KATHLEEN TRINETTE COSTELLO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC19879	AZ
2	101YP2500X	Professional Counselor	LPC-19879	AZ

General Provider Information

NPI Number	:	1619614625
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN TRINETTE COSTELLO

Provider Business Mailing Address
First Line	:	13527 E SUMMIT DR
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85259-2222
Country	:	US
Telephone Number	:	719-439-0250
Fax Number	:

Provider Business Practice Location Address
First Line	:	8700 E VISTA BONITA DR STE 188
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85255-3205
Country	:	US
Telephone Number	:	480-506-9747
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2022
Last Update Date	:	10/23/2023

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Directions to “ KATHLEEN TRINETTE COSTELLO ” Practice Location

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