Provider Demographics
NPI:1235403304
Name:CUSTODE, AIDA MARIA
Entity Type:Individual
Prefix:
First Name:AIDA
Middle Name:MARIA
Last Name:CUSTODE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9516 SW 117TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-2122
Mailing Address - Country:US
Mailing Address - Phone:305-725-8599
Mailing Address - Fax:
Practice Address - Street 1:440 SAWGRASS CORPORATE PKWY STE 106
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33325-6236
Practice Address - Country:US
Practice Address - Phone:954-745-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral