=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407797541
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON KIANA COSTELLO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2026
-----------------------------------------------------
Last Update Date | 04/02/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 460 BLOOMFIELD AVE STE 209
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-3552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-674-9857
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 ALEXANDRIA RD
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07960-3638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-349-2994
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 37AC00952600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------