Individual
NICOLE COSTELLO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MS.PSY,CRADC,MOUD,CS
Contact information
Practice address
2919 E 4TH ST, CORPORATE HOME BASE ASSIGNMENT, JOPLIN, MO 64801-1625
(417) 782-7966
(417) 624-4558
Mailing address
2919 E 4TH ST, JOPLIN, MO 64801-1625
(503) 983-1621
(417) 624-4558
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
14770
MO
171M00000X
Case Manager/Care Coordinator
93-6002307
OR
247000000X
Health Information Technician
—
MO
251S00000X
Community/Behavioral Health Agency
Primary
14770
MO
261QM0850X
Adult Mental Health Clinic/Center
1922
MO
261QM2800X
Methadone Clinic
14770
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
122994
—
OR
Enumeration date
07/23/2020
Last updated
01/07/2026
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