Provider Demographics
NPI:1619745908
Name:DANDRIDGE, AD-ASTRA CUSTIS
Entity Type:Individual
Prefix:MISS
First Name:AD-ASTRA
Middle Name:CUSTIS
Last Name:DANDRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:AINSLEY
Other - Middle Name:CUSTIS
Other - Last Name:DANDRIDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1020 TRIUMPHANT ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-3918
Mailing Address - Country:US
Mailing Address - Phone:702-503-0848
Mailing Address - Fax:
Practice Address - Street 1:1020 TRIUMPHANT ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-3918
Practice Address - Country:US
Practice Address - Phone:702-503-0848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician