Basic Information
| Provider Information | |||||||||
| NPI: | 1871714998 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CUSTODERO | ||||||||
| FirstName: | MARIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 W RED OAK LN STE 201 | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106043603 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 EASTGATE DR | ||||||||
| Address2: | |||||||||
| City: | AIKEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8036433694 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 09/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251G0304X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics |
ID Information
| ID | Type | State | Issuer | Description | 887462000 | 05 | FL | MEDICAID |