| Doctor Name: | MR. KENNETH PATRICK COSTELLO |
| NPI Number: | 1265586572 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | 2002005830 |
| Business Practice Address: | 10859 West Florissant Avenue Ferguson, MO - 63136 |
| Business Phone Number: | 3145213000 |
| Business Fax Number: | 3145217800 |
| Mailing Address: | 1211 Drayton Ave, WEBSTER GROVES |
| State: | MO |
| Postal Code: | 631194704 |
| Phone Number: | 3149689626 |
| Fax Number: | |
| NPI Enumeration Date: | 01/23/2007 |
| NPI Last Update Date: | 10/15/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225100000X |
| License Number: | 2002005830 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MO |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) Physical therapists are health care professionals who evaluate and treat people with health problems resulting from injury or disease. PT |