Provider Demographics
NPI:1962397364
Name:COSTELLO, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 PERSIMMON
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-5365
Mailing Address - Country:US
Mailing Address - Phone:918-816-9169
Mailing Address - Fax:
Practice Address - Street 1:2801 PERSIMMON
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-5365
Practice Address - Country:US
Practice Address - Phone:918-816-9169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator