Provider Demographics
NPI:1861711434
Name:COSTELLO, CRAIG DOUGLAS
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:DOUGLAS
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12755 BROOKHURST ST
Mailing Address - Street 2:116
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12755 BROOKHURST ST
Practice Address - Street 2:116
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4857
Practice Address - Country:US
Practice Address - Phone:714-638-8277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor