Provider Demographics
NPI:1740678564
Name:CUSTODIO, EVELYN C
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:C
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 1:1915 HARMAN ST APT B
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-1930
Mailing Address - Country:US
Mailing Address - Phone:347-658-3858
Mailing Address - Fax:
Practice Address - Street 1:1915 HARMAN ST APT B
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-1930
Practice Address - Country:US
Practice Address - Phone:347-658-3858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-31
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist