Provider Demographics
NPI:1730638164
Name:CUSTEAD, MARIE COLLINS
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:COLLINS
Last Name:CUSTEAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:COLLINS
Other - Last Name:CUSTEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:SFA ATHLETIC FIELDHOUSE 712 HAYTER ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75962-0001
Mailing Address - Country:US
Mailing Address - Phone:936-468-3506
Mailing Address - Fax:936-468-4052
Practice Address - Street 1:SFA ATHLETIC FIELDHOUSE 712 HAYTER ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75962-0001
Practice Address - Country:US
Practice Address - Phone:936-468-3506
Practice Address - Fax:936-468-4052
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT84467133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered