Provider Demographics
NPI:1871538017
Name:COSTILLA, ELLEN TERESA (LISW)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:TERESA
Last Name:COSTILLA
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 CARMEL RD
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-9200
Mailing Address - Country:US
Mailing Address - Phone:505-764-6409
Mailing Address - Fax:505-764-6455
Practice Address - Street 1:2741 INDIAN SCHOOL RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2653
Practice Address - Country:US
Practice Address - Phone:505-255-8682
Practice Address - Fax:505-255-7890
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-046031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical