Healthcare Provider Details

I. General information

NPI: 1083484398
Provider Name (Legal Business Name): TIFFANY COSTELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 GALILEO DR STE 102
TRINITY FL
34655-1852
US

IV. Provider business mailing address

3226 TOWN AVE
NEW PORT RICHEY FL
34655-2167
US

V. Phone/Fax

Practice location:
  • Phone: 727-261-0508
  • Fax:
Mailing address:
  • Phone: 727-237-5271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW21207
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: