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General NPI Number Information
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NPI Number | 1245943711
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Entity Type | Individual
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Provider Name | KATHLEEN ELAINE-SMALL CUSTODIO
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Gender | Female
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Dates
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Enumeration Date | 12/29/2022
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Last Update Date | 10/02/2025
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Provider Practice Location Address
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Address Line | 1800 PARK NEWPORT APT 206
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City | NEWPORT BEACH
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State | CA
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Zip | 92660-5040
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Country | US
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Telephone | 714-478-7077
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 80145
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City | RANCHO SANTA MARGARITA
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State | CA
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Zip | 92688-0145
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Country | US
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Telephone | 714-478-7077
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State | CA
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