Provider Demographics
NPI:1174187322
Name:BUENTELLO, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BUENTELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 W JOHNSTON AVE TRLR 94
Mailing Address - Street 2:
Mailing Address - City:KINGSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78363-4988
Mailing Address - Country:US
Mailing Address - Phone:361-355-1148
Mailing Address - Fax:
Practice Address - Street 1:1231 AGNES ST STE A18
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78401-3202
Practice Address - Country:US
Practice Address - Phone:361-882-1413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11362101YA0400X
TX68348101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional