Healthcare Provider Details

I. General information

NPI: 1841628617
Provider Name (Legal Business Name): MRS. VANESSA COSTELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2013
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 W CADDO ST
CLEVELAND OK
74020-4201
US

IV. Provider business mailing address

907 W CADDO ST
CLEVELAND OK
74020-4201
US

V. Phone/Fax

Practice location:
  • Phone: 918-308-5511
  • Fax:
Mailing address:
  • Phone: 918-308-5511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: