Provider Demographics
NPI:1669860011
Name:CUSTODIO, MARIAN
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:
Last Name:CUSTODIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 LACROSSE PL
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-6358
Mailing Address - Country:US
Mailing Address - Phone:619-888-1832
Mailing Address - Fax:619-231-7040
Practice Address - Street 1:720 LACROSSE PL
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-6358
Practice Address - Country:US
Practice Address - Phone:619-888-1832
Practice Address - Fax:619-231-7040
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9474225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant