MEDICARE: KELLY LYNN COSTELLO BCBA

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	103K00000X	Behavior Analyst	1-15-19490

General Provider Information

NPI Number	:	1194177949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY LYNN COSTELLO BCBA

Provider Business Mailing Address
First Line	:	4103 LESTER CT
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22311-1121
Country	:	US
Telephone Number	:	615-335-5844
Fax Number	:

Provider Business Practice Location Address
First Line	:	4103 LESTER CT
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22311-1121
Country	:	US
Telephone Number	:	615-335-5844
Fax Number	:

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

Provider Enumeration Date	:	07/05/2016
Last Update Date	:	07/05/2016

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