Healthcare Provider Details

I. General information

NPI: 1922914506
Provider Name (Legal Business Name): JUSTIN COSTELLO PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W REDLANDS BLVD STE B
REDLANDS CA
92373-4642
US

IV. Provider business mailing address

1049 N CALIFORNIA AVE
BEAUMONT CA
92223-1619
US

V. Phone/Fax

Practice location:
  • Phone: 909-686-6233
  • Fax:
Mailing address:
  • Phone: 951-634-5745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95040962
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: