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General NPI Number Information
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NPI Number | 1871256453
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Entity Type | Organization
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Legal Business Name | MICHELLE A COSTELLO LCSW, PLLC
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Dates
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Enumeration Date | 10/20/2021
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Last Update Date | 10/22/2021
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Provider Practice Location Address
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Address Line | 5215 N RAVENSWOOD AVE STE 214
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City | CHICAGO
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State | IL
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Zip | 60640-1670
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Country | US
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Telephone | 312-476-9722
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Fax |
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Provider Business Mailing Address
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Address Line | 615 HINMAN AVE APT 3D
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City | EVANSTON
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State | IL
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Zip | 60202-3047
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Country | US
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Telephone | 312-593-3553
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Fax |
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Authorized Official
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Title or Position | REGISTERED AGENT
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Name | MICHELLE ALYSE COSTELLO
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Credential | LCSW
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Telephone | 312-593-3553
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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