Provider Demographics
NPI:1861936270
Name:CUSTER, WHITNEY M (PT)
Entity type:Individual
Prefix:
First Name:WHITNEY
Middle Name:M
Last Name:CUSTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:WHITNEY
Other - Middle Name:M
Other - Last Name:BOEHME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1990 GREEN TREE DR
Mailing Address - Street 2:
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467-2304
Mailing Address - Country:US
Mailing Address - Phone:262-389-5723
Mailing Address - Fax:
Practice Address - Street 1:BELLA VISTA 631 HAZEL ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-4600
Practice Address - Country:US
Practice Address - Phone:262-389-5723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-05
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13008-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist