Provider Demographics
NPI:1902063365
Name:COSTELLO, WENDY WILSON (MFT 14554)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:WILSON
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MFT 14554
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 FILLMORE ST
Mailing Address - Street 2:NO. 204
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94123-3470
Mailing Address - Country:US
Mailing Address - Phone:415-922-7773
Mailing Address - Fax:
Practice Address - Street 1:3109 FILLMORE ST
Practice Address - Street 2:NO. 204
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123-3470
Practice Address - Country:US
Practice Address - Phone:415-922-7773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 14554106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist