Provider Demographics
NPI:1083087639
Name:BUSTILLO, NATALIE ESCOBIO (PHD)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:ESCOBIO
Last Name:BUSTILLO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:NATALIE
Other - Middle Name:
Other - Last Name:ESCOBIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10351 SW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-2714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4601 PONCE DE LEON BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2111
Practice Address - Country:US
Practice Address - Phone:305-894-6754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9388103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical