Healthcare Provider Details

I. General information

NPI: 1639843659
Provider Name (Legal Business Name): COURTNEY COSTELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 GEORGETOWN SUITE A3
STOCKTON CA
95207
US

IV. Provider business mailing address

10400 FRICOT CITY RD
SAN ANDREAS CA
95249-9642
US

V. Phone/Fax

Practice location:
  • Phone: 209-955-1139
  • Fax:
Mailing address:
  • Phone: 209-736-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT144592
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: