Healthcare Provider Details

I. General information

NPI: 1831372051
Provider Name (Legal Business Name): COURTNEY DARLENE CUSTER MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2403 SAN MATEO BLVD NE SUITE S-14
ALBUQUERQUE NM
87110-4058
US

IV. Provider business mailing address

12820 JOELLE RD NE
ALBUQUERQUE NM
87112-2558
US

V. Phone/Fax

Practice location:
  • Phone: 505-830-1871
  • Fax: 505-830-0040
Mailing address:
  • Phone: 505-301-3036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: