Provider Demographics
NPI:1679702427
Name:COSTELLO, THOMAS (LCSW)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27588-0024
Mailing Address - Country:US
Mailing Address - Phone:984-389-0566
Mailing Address - Fax:
Practice Address - Street 1:335 S WHITE ST
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-2916
Practice Address - Country:US
Practice Address - Phone:984-389-0566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0047561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical