Healthcare Provider Details

I. General information

NPI: 1205743820
Provider Name (Legal Business Name): AMY COSTELLO PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10712 QUEENS BLVD
FOREST HILLS NY
11375-4249
US

IV. Provider business mailing address

102 MADISON AVE FL 8
NEW YORK NY
10016-7584
US

V. Phone/Fax

Practice location:
  • Phone: 646-222-9640
  • Fax: 646-805-1365
Mailing address:
  • Phone: 212-759-2282
  • Fax: 212-379-2123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number056335
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: