Farah Grace Custodio
Physical Therapist, Orthopedic in Forest Grove, OR. Individual provider (NPI-1).
NPI number1740924620
StatusActive
Last updated in NPPESOct 22, 2024
Details
- NPI
- 1740924620
- Entity type
- Individual (NPI-1)
- Name
- Farah Grace Custodio
- Sex
- Female
- Sole proprietor
- Yes
- Enumeration date
- Apr 26, 2022
- Certification date
- Oct 22, 2024
- Last updated
- Oct 22, 2024
Medicare and OIG
- Medicare enrolled (PECOS)
- Yes · PRACTITIONER - PHYSICAL THERAPIST IN PRIVATE PRACTICE
- Can order and refer
- Not on the CMS order and referring list
- OIG exclusion list
- This NPI is not listed
CMS and OIG files of November 2026. PECOS lookup · OIG exclusion check
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 2251X0800X | Physical Therapist, Orthopedic | 64412 | OR | Yes |
| 261QP2000X | Clinic/Center, Physical Therapy | 64412 | OR |
Practice location
3838 Pacific AveForest Grove, OR 97116-2224
Phone 503-357-1706
Mailing address
1000 Nw 123rd Ave Apt 1Portland, OR 97229-5673
Phone 503-804-1072
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