Provider Demographics
NPI:1811767890
Name:CUSTER, TAYLOR
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:CUSTER
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 1:37 NORTHERN BLVD UNIT 130
Mailing Address - Street 2:
Mailing Address - City:GREENVALE
Mailing Address - State:NY
Mailing Address - Zip Code:11548-4006
Mailing Address - Country:US
Mailing Address - Phone:646-413-8336
Mailing Address - Fax:
Practice Address - Street 1:24125 BRADDOCK AVE
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-1150
Practice Address - Country:US
Practice Address - Phone:646-413-8336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst