Basic Information
| Provider Information | |||||||||
| NPI: | 1790266773 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTELLO | ||||||||
| FirstName: | BRIANA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 BRAMHALL ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041023175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076620111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 71 US ROUTE 1 STE C | ||||||||
| Address2: | |||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040747174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078835532 | ||||||||
| FaxNumber: | 2078835552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2018 | ||||||||
| LastUpdateDate: | 05/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LC17949 | ME | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | MC16511 | ME | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.