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General NPI Number Information
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NPI Number | 1598110512
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Entity Type | Individual
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Provider Name | MONIQUE COSTELLO LCSW
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Gender | Female
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Dates
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Enumeration Date | 04/27/2016
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Last Update Date | 04/27/2016
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Provider Practice Location Address
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Address Line | 9378 OLIVE BLVD STE 317
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City | SAINT LOUIS
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State | MO
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Zip | 63132-3215
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Country | US
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Telephone | 314-994-9344
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Fax |
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Provider Business Mailing Address
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Address Line | 9706 HALE DR
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City | SAINT LOUIS
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State | MO
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Zip | 63123-5523
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Country | US
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Telephone | 314-808-7501
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Fax |
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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 | 2015002313
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License Number State | MO
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