Provider Demographics
NPI:1407428345
Name:BUSTAMANTE, GABRIELLA E
Entity Type:Individual
Prefix:MISS
First Name:GABRIELLA
Middle Name:E
Last Name:BUSTAMANTE
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 1:5823 E NEW YORK ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-5921
Mailing Address - Country:US
Mailing Address - Phone:317-658-8397
Mailing Address - Fax:
Practice Address - Street 1:8350 CRAIG ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-3593
Practice Address - Country:US
Practice Address - Phone:317-578-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician