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NPI Code Detail

MEDICARE: KERRY COSTELLO MFT

MEDICARE: KERRY COSTELLO MFT
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
1101YM0800XMental Health Counselor40123CA
2101Y00000XCounselor40123CA
3106H00000XMarriage & Family Therapist40123CA

General Provider Information

NPI Number : 1285385849
Entity Type Code : Individual
Provider Name (Legal Business Name) : KERRY COSTELLO MFT
Provider Business Mailing Address
First Line : 44 DUVALI DR
Second Line :
City : VENTURA
State : CA
Zip : 93003-2151
Country : US
Telephone Number : 805-415-2441
Fax Number :
Provider Business Practice Location Address
First Line : 1317 DEL NORTE RD STE 200
Second Line :
City : CAMARILLO
State : CA
Zip : 93010-8368
Country : US
Telephone Number : 805-415-2441
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/14/2022
Last Update Date : 01/14/2026

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