Healthcare Provider Details

I. General information

NPI: 1871714998
Provider Name (Legal Business Name): MARIE CUSTODERO P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 09/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 EASTGATE DR
AIKEN SC
29803
US

IV. Provider business mailing address

4 W RED OAK LN STE 201
WHITE PLAINS NY
10604-3603
US

V. Phone/Fax

Practice location:
  • Phone: 803-643-3694
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier887462000
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: