Provider Demographics
NPI:1376271221
Name:BUSTILLOS, MARICELA
Entity Type:Individual
Prefix:
First Name:MARICELA
Middle Name:
Last Name:BUSTILLOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 W HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-2709
Mailing Address - Country:US
Mailing Address - Phone:575-942-1661
Mailing Address - Fax:
Practice Address - Street 1:18 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-4023
Practice Address - Country:US
Practice Address - Phone:575-739-2705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4682224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant