Individual
LISA HUMPHREY COSTELLO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PH.D., NCSP
Contact information
Practice address
13123 E 16TH AVE, AURORA, CO 80045-7106
(720) 777-1234
Mailing address
PO BOX 110429, AURORA, CO 80042-0429
Taxonomy
Speciality
Code
Description
License number
State
103TC2200X
Clinical Child & Adolescent Psychologist
PS01229
RI
103TC2200X
Clinical Child & Adolescent Psychologist
Primary
PSY.0004029
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PS01229
PROFESSIONAL LICENSE
RI
Enumeration date
07/07/2011
Last updated
11/19/2019
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