Basic Information
| Provider Information | |||||||||
| NPI: | 1841366390 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSTELLO | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS OTRL | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRYLE | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | T | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MS OTRL | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1086 ROUTE 315 | ||||||||
| Address2: | PRO REHABILITATION SERVICES | ||||||||
| City: | PLAINS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708237761 | ||||||||
| FaxNumber: | 5708228033 | ||||||||
| Practice Location | |||||||||
| Address1: | 1086 ROUTE 315 | ||||||||
| Address2: | PRO REHABILITATION SERVICES | ||||||||
| City: | PLAINS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708237761 | ||||||||
| FaxNumber: | 5708228033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OC010142 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 821397 | 01 | FIRST PRIORITY | OTHER | 1938013 | 01 | BLUE SHIELD | OTHER | 821383 | 01 | FIRST PRIORITY | OTHER | 821396 | 01 | FIRST PRIORITY | OTHER |