Provider Demographics
NPI:1700939451
Name:CUSTER, LE EDNA MARIE (MA)
Entity Type:Individual
Prefix:MS
First Name:LE EDNA
Middle Name:MARIE
Last Name:CUSTER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:LE
Other - Middle Name:
Other - Last Name:KNIGHT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:PO BOX 6041
Mailing Address - Street 2:
Mailing Address - City:CAREFREE
Mailing Address - State:AZ
Mailing Address - Zip Code:85377
Mailing Address - Country:US
Mailing Address - Phone:480-575-8544
Mailing Address - Fax:480-575-8299
Practice Address - Street 1:4525 N GRANITE REEF RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-1719
Practice Address - Country:US
Practice Address - Phone:480-484-2607
Practice Address - Fax:480-484-2601
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ579568OtherAHCCS