Provider Demographics
NPI:1730141433
Name:COSTELLO, THERESA (PHD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2158 INTELLIPLEX DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-8549
Mailing Address - Country:US
Mailing Address - Phone:317-398-2812
Mailing Address - Fax:
Practice Address - Street 1:2158 INTELLIPLEX DR STE 200
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-8549
Practice Address - Country:US
Practice Address - Phone:317-398-2812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042231A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RITC42754Medicaid