Healthcare Provider Details

I. General information

NPI: 1053123729
Provider Name (Legal Business Name): THOMAS JOHN COSTELLO JR. MOTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TOMMY JOHN COSTELLO JR. MOTR/L

II. Dates (important events)

Enumeration Date: 01/21/2025
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16528 E DESMET CT STE B2200
SPOKANE VALLEY WA
99216-3522
US

IV. Provider business mailing address

PO BOX 31001-4114
PASADENA CA
91110-4114
US

V. Phone/Fax

Practice location:
  • Phone: 509-944-8920
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT61647885
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: