Provider Demographics
NPI:1366109761
Name:CUSTODIO, SANDRA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:CUSTODIO
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 CAUBLE DR
Mailing Address - Street 2:
Mailing Address - City:FATE
Mailing Address - State:TX
Mailing Address - Zip Code:75087-6779
Mailing Address - Country:US
Mailing Address - Phone:214-287-5184
Mailing Address - Fax:
Practice Address - Street 1:3020 POTEET DR
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4762
Practice Address - Country:US
Practice Address - Phone:972-882-7233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113901235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist