Provider Demographics
NPI:1194540278
Name:CUSTER, ELIZABETH ELLEN
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ELLEN
Last Name:CUSTER
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 1:1144 GATEWAY LOOP
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-7731
Mailing Address - Country:US
Mailing Address - Phone:541-698-6908
Mailing Address - Fax:
Practice Address - Street 1:1144 GATEWAY LOOP
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-7731
Practice Address - Country:US
Practice Address - Phone:541-698-6908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker