Individual
FARAH GRACE CUSTODIO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
3838 PACIFIC AVE, FOREST GROVE, OR 97116-2224
(503) 357-1706
Mailing address
1000 NW 123RD AVE APT 1, PORTLAND, OR 97229-5673
(503) 804-1072
Taxonomy
Speciality
Code
Description
License number
State
2251X0800X
Orthopedic Physical Therapist
Primary
64412
OR
261QP2000X
Physical Therapy Clinic/Center
64412
OR
Other
Enumeration date
04/26/2022
Last updated
10/22/2024
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