Healthcare Provider Details

I. General information

NPI: 1013526318
Provider Name (Legal Business Name): NICOLE COSTELLO MS.PSY,CRADC,MOUD,CS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NIKI COSTELLO MS.PSY,CRADC,MOUD,CS

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2919 E 4TH ST CORPORATE HOME BASE ASSIGNMENT
JOPLIN MO
64801-1625
US

IV. Provider business mailing address

2919 E 4TH ST
JOPLIN MO
64801-1625
US

V. Phone/Fax

Practice location:
  • Phone: 417-782-7966
  • Fax: 417-624-4558
Mailing address:
  • Phone: 503-983-1621
  • Fax: 417-624-4558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number1922
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number14770
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14770
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code247000000X
TaxonomyHealth Information Technician
License Number
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number93-6002307
License Number StateOR
# 6
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number14770
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: