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General NPI Number Information
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NPI Number | 1215987201
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Entity Type | Individual
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Provider Name | SHANNON BROOK COSTELLA MSPT, CERT MDT
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Gender | Female
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Dates
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Enumeration Date | 05/11/2006
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Last Update Date | 04/20/2017
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Provider Practice Location Address
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Address Line | 2307 LAPORTE AVE SUITE 5
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City | VALPARAISO
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State | IN
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Zip | 46383-6996
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Country | US
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Telephone | 219-477-4500
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Fax | 219-477-4567
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Provider Business Mailing Address
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Address Line | 625 ENTERPRISE DR
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City | OAK BROOK
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State | IL
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Zip | 60523-8813
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Country | US
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Telephone | 630-575-6200
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Fax | 630-928-5040
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 05007003A
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License Number State | IN
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