Basic Information
| Provider Information | |||||||||
| NPI: | 1255605242 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSTILOW | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COSTILOW | ||||||||
| OtherFirstName: | ANN | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2626 CHARLES DR | ||||||||
| Address2: | |||||||||
| City: | CHALMETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700433779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042784006 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2626 CHARLES DR | ||||||||
| Address2: | |||||||||
| City: | CHALMETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700433779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042784006 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2012 | ||||||||
| LastUpdateDate: | 04/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 11051 | LA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 00018214 | 05 | MS | MEDICAID |