=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447966262
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE LYN COSTLOW PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2023
-----------------------------------------------------
Last Update Date | 12/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 S BROADWAY AVE STE 608
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75702-7281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-360-7587
-----------------------------------------------------
Fax | 979-446-0280
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1511 TEXAS AVE S PMB 233 PMB 233
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802-3475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-360-7587
-----------------------------------------------------
Fax | 979-446-0280
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 1099356
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 74683
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | C-APN.0101005-C-NP
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------