Healthcare Provider Details

I. General information

NPI: 1447966262
Provider Name (Legal Business Name): MICHELLE LYN COSTLOW PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 S BROADWAY AVE STE 608
TYLER TX
75702-7281
US

IV. Provider business mailing address

1511 TEXAS AVE S PMB 233 PMB 233
BRYAN TX
77802-3475
US

V. Phone/Fax

Practice location:
  • Phone: 888-360-7587
  • Fax: 979-446-0280
Mailing address:
  • Phone: 888-360-7587
  • Fax: 979-446-0280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1099356
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number74683
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberC-APN.0101005-C-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: