Healthcare Provider Details

I. General information

NPI: 1306926233
Provider Name (Legal Business Name): KIM K COSTELLO M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 I-55 NORTH SUITE 291, HIGHLAND VILLAGE
JACKSON MS
39211
US

IV. Provider business mailing address

1006 CANTERBURY PL E
BRANDON MS
39042-8105
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-0859
  • Fax: 601-362-0870
Mailing address:
  • Phone: 601-825-5678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSO780
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: