Provider Demographics
NPI:1346720679
Name:BUSTAMANTE, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:BUSTAMANTE
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 1:1801 HUNTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-2635
Mailing Address - Country:US
Mailing Address - Phone:626-993-3000
Mailing Address - Fax:
Practice Address - Street 1:1801 HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-2635
Practice Address - Country:US
Practice Address - Phone:626-993-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW1160161041C0700X
CAACSW90514104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical