Provider Demographics
NPI:1053123729
Name:COSTELLO, THOMAS JOHN JR (MOTR/L)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JOHN
Last Name:COSTELLO
Suffix:JR
Gender:M
Credentials:MOTR/L
Other - Prefix:MR
Other - First Name:TOMMY
Other - Middle Name:JOHN
Other - Last Name:COSTELLO
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MOTR/L
Mailing Address - Street 1:11305 E 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-2912
Mailing Address - Country:US
Mailing Address - Phone:509-998-2485
Mailing Address - Fax:
Practice Address - Street 1:5322 N DIVISION ST STE 102
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-1300
Practice Address - Country:US
Practice Address - Phone:509-487-1232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT61647885225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist