Provider Demographics
NPI:1609099407
Name:CUSTY, DIANE MARIE (PT)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:MARIE
Last Name:CUSTY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 271498
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80527-1498
Mailing Address - Country:US
Mailing Address - Phone:994-036-8829
Mailing Address - Fax:
Practice Address - Street 1:512 E MONROE DR UNIT D431
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-2796
Practice Address - Country:US
Practice Address - Phone:994-036-8829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1017598225100000X
CO0011886225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist