Provider Demographics
NPI:1295924983
Name:CUSTODE, DANIELLE (DC)
Entity type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:
Last Name:CUSTODE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 TABLE MESA DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-5869
Mailing Address - Country:US
Mailing Address - Phone:303-499-9442
Mailing Address - Fax:303-494-8678
Practice Address - Street 1:3400 TABLE MESA DR
Practice Address - Street 2:SUITE 201
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-5869
Practice Address - Country:US
Practice Address - Phone:303-499-9442
Practice Address - Fax:303-494-8678
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor