Individual
KELLY N COSTELLO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
4622 40TH AVE S STE B, FARGO, ND 58104-4394
(701) 361-3745
Mailing address
4622 40TH AVE S STE B, FARGO, ND 58104-4394
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
103733
MN
Other
Enumeration date
06/09/2009
Last updated
01/08/2014
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