Healthcare Provider Details

I. General information

NPI: 1598687634
Provider Name (Legal Business Name): RAYMOND ANDREW CUSTIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 BLACKBURN LN STE 150
BURTONSVILLE MD
20866-6127
US

IV. Provider business mailing address

15804 RADWICK LN
SILVER SPRING MD
20906-1036
US

V. Phone/Fax

Practice location:
  • Phone: 301-421-4241
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP17714
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: