Provider Demographics
NPI:1669365300
Name:COSTELLO, SARA
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 PALM AVE APT 41
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-2931
Mailing Address - Country:US
Mailing Address - Phone:619-972-1460
Mailing Address - Fax:
Practice Address - Street 1:667 LIGHTHOUSE AVE STE 201
Practice Address - Street 2:
Practice Address - City:PACIFIC GROVE
Practice Address - State:CA
Practice Address - Zip Code:93950-2666
Practice Address - Country:US
Practice Address - Phone:831-318-0558
Practice Address - Fax:831-603-6061
Is Sole Proprietor?:No
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist