Healthcare Provider Details

I. General information

NPI: 1366939183
Provider Name (Legal Business Name): CHRISTINE COSTELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 SHOREHAM PL STE 100
SAN DIEGO CA
92122-5904
US

IV. Provider business mailing address

4510 EXECUTIVE DR STE 315
SAN DIEGO CA
92121-3029
US

V. Phone/Fax

Practice location:
  • Phone: 858-427-5060
  • Fax: 619-383-6701
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: