Provider Demographics
NPI:1124361688
Name:CUSTOMIZED MEDICAL NEEDS
Entity type:Organization
Organization Name:CUSTOMIZED MEDICAL NEEDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTI
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-563-7772
Mailing Address - Street 1:2129 WEST STREET
Mailing Address - Street 2:SUITE 224
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3837
Mailing Address - Country:US
Mailing Address - Phone:866-563-7772
Mailing Address - Fax:901-255-0758
Practice Address - Street 1:2129 WEST STREET
Practice Address - Street 2:SUITE 224
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3837
Practice Address - Country:US
Practice Address - Phone:866-563-7772
Practice Address - Fax:901-255-0758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-03
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN305101YP2500X
104100000X, 133V00000X, 163W00000X, 224Z00000X, 225100000X, 225200000X, 235Z00000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1531379Medicaid
TN103G700897OtherMEDICARE (PTAN)