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General NPI Number Information
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NPI Number | 1356976120
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Entity Type | Individual
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Provider Name | RACHAEL SHANNEL COSTLY
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Gender | Female
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Dates
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Enumeration Date | 03/11/2020
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Last Update Date | 03/11/2020
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Provider Practice Location Address
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Address Line | 9500 COUNTY ROAD 190
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City | MANVEL
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State | TX
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Zip | 77578-5078
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Country | US
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Telephone | 225-788-7048
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Fax |
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Provider Business Mailing Address
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Address Line | 6811 LAUGHLIN DR
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City | MISSOURI CITY
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State | TX
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Zip | 77489-3412
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Country | US
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Telephone | 225-788-7048
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Fax | 832-787-1218
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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 | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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