Individual
TARA MARIE COSTELLO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
304 MAIN ST STE A, FARMINGTON, CT 06032-2985
(845) 490-7830
Mailing address
1466 CHRISTINE RD, MOHEGAN LAKE, NY 10547-1761
(845) 490-7830
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
—
—
Other
Enumeration date
08/14/2024
Last updated
08/14/2024
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