1780737379 NPI number — MR. RALPH WILLIAM COSTELLO MFT

Table of content: MR. RALPH WILLIAM COSTELLO MFT (NPI 1780737379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780737379 NPI number — MR. RALPH WILLIAM COSTELLO MFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COSTELLO
Provider First Name:
RALPH
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780737379
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
161 FASHION LANE
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
TUSTIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92780
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-669-9120
Provider Business Mailing Address Fax Number:
714-669-9120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
161 FASHION LANE
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
TUSTIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-669-9120
Provider Business Practice Location Address Fax Number:
714-669-9120
Provider Enumeration Date:
01/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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