Provider Demographics
NPI:1740388412
Name:CUSTODIO, MARY ROSE L
Entity Type:Individual
Prefix:
First Name:MARY ROSE L
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 1:1508 AVENUE U
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-3808
Mailing Address - Country:US
Mailing Address - Phone:718-376-3383
Mailing Address - Fax:718-376-3385
Practice Address - Street 1:1508 AVENUE U
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-3808
Practice Address - Country:US
Practice Address - Phone:718-376-3383
Practice Address - Fax:718-376-3385
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026493-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ6651EM171Medicare PIN