Basic Information
| Provider Information | |||||||||
| NPI: | 1215257720 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTELLO | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | RAY | ||||||||
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| Credential: | CADC 1 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1641 D ST NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973012664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039104531 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3180 CENTER ST NE | ||||||||
| Address2: | DRUG TREATMENT | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973014592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035764660 | ||||||||
| FaxNumber: | 5033612688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2010 | ||||||||
| LastUpdateDate: | 06/07/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 08-08-10 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.