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General NPI Number Information
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NPI Number | 1548981582
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Entity Type | Individual
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Provider Name | ANDREA SUE COSTON LSW
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Gender | Female
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Dates
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Enumeration Date | 09/08/2022
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Last Update Date | 05/14/2025
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Provider Practice Location Address
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Address Line | 102 E. CHESTNUT
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City | BLOOMINGTON
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State | IL
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Zip | 61701
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Country | US
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Telephone | 309-490-3060
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Fax | 704-980-3082
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Provider Business Mailing Address
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Address Line | 500 MANCHESTER RD
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City | NORMAL
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State | IL
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Zip | 61761-1520
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Country | US
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Telephone | 309-826-3878
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Fax | 704-980-3082
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | P018410
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 150111370
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License Number State | IL
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