Provider Demographics
NPI:1740924620
Name:CUSTODIO, FARAH GRACE
Entity type:Individual
Prefix:
First Name:FARAH
Middle Name:GRACE
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 1:1000 NW 123RD AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5673
Mailing Address - Country:US
Mailing Address - Phone:503-804-1072
Mailing Address - Fax:
Practice Address - Street 1:3838 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2224
Practice Address - Country:US
Practice Address - Phone:503-357-1706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR64412261QP2000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty