Provider Demographics
NPI:1548779788
Name:CUSTODIO, MARI JOSEPHINE SY (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARI JOSEPHINE
Middle Name:SY
Last Name:CUSTODIO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:JOSEPHINE
Other - Middle Name:SY
Other - Last Name:CUSTODIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:22704 VOSE ST
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-2319
Mailing Address - Country:US
Mailing Address - Phone:818-486-2884
Mailing Address - Fax:
Practice Address - Street 1:14445 OLIVE VIEW DR
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1437
Practice Address - Country:US
Practice Address - Phone:747-210-4245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4037225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist