Basic Information
| Provider Information | |||||||||
| NPI: | 1285959593 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUSTODIO | ||||||||
| FirstName: | ALVIN | ||||||||
| MiddleName: | BUADA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 328 N SAN MATEO DR STE C | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944012514 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1801 VICENTE ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941162923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156813211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2010 | ||||||||
| LastUpdateDate: | 02/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 76768 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 101319 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.