Provider Demographics
NPI:1457657702
Name:BUSTOS, SANDRA (OTA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5979 NW 151ST ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-2400
Mailing Address - Country:US
Mailing Address - Phone:305-362-3300
Mailing Address - Fax:305-362-0202
Practice Address - Street 1:5979 NW 151ST ST
Practice Address - Street 2:SUITE 108
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2400
Practice Address - Country:US
Practice Address - Phone:305-362-3300
Practice Address - Fax:305-362-0202
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA10504224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant