Provider Demographics
NPI:1861761462
Name:COSTELLO, JULIE (LCMFT)
Entity type:Individual
Prefix:DR
First Name:JULIE
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:LCMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 N BROADWAY ST STE E
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-2684
Mailing Address - Country:US
Mailing Address - Phone:620-644-3013
Mailing Address - Fax:
Practice Address - Street 1:2809 N BROADWAY ST STE E
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-2684
Practice Address - Country:US
Practice Address - Phone:620-644-3013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-28
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018038211106H00000X
GAMFT001291106H00000X
NC1470106H00000X
KS2875106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12432779OtherCAQH PROVIDER NUMBER