MEDICARE: KATHLEEN TERESA COSTELLO L.AC

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	171100000X	Acupuncturist	007122	NY

General Provider Information

NPI Number	:	1356055610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN TERESA COSTELLO L.AC

Provider Business Mailing Address
First Line	:	1239 N COUNTRY RD STE 3
Second Line	:
City	:	STONY BROOK
State	:	NY
Zip	:	11790-1920
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1239 N COUNTRY RD STE 3
Second Line	:
City	:	STONY BROOK
State	:	NY
Zip	:	11790-1920
Country	:	US
Telephone Number	:	631-601-6491
Fax Number	:

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

Provider Enumeration Date	:	01/11/2023
Last Update Date	:	01/11/2023

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