Provider Demographics
NPI:1972910933
Name:CUSTOM CARE TEAM, INC.
Entity Type:Organization
Organization Name:CUSTOM CARE TEAM, INC.
Other - Org Name:MED TEAM THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PROGRAM AND POLICY DEVE
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:V
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, RN
Authorized Official - Phone:210-270-1355
Mailing Address - Street 1:1902 CAMPUS COMMONS DR STE 650
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-1589
Mailing Address - Country:US
Mailing Address - Phone:703-390-2300
Mailing Address - Fax:703-390-5819
Practice Address - Street 1:1915 BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340-1173
Practice Address - Country:US
Practice Address - Phone:734-779-9799
Practice Address - Fax:734-779-9796
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE MEDICAL TEAM, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-22
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty