MEDICARE: DEBBIE ELIZABETH COSTELLO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253J00000X	Foster Care Agency
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1184119943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBBIE ELIZABETH COSTELLO

Provider Business Mailing Address
First Line	:	1129 URANA AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43224-3334
Country	:	US
Telephone Number	:	503-757-5095
Fax Number	:

Provider Business Practice Location Address
First Line	:	5655 NORTH HIGH ST.
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43085
Country	:	US
Telephone Number	:	614-885-0920
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2018
Last Update Date	:	05/01/2019

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