Provider Demographics
NPI:1497243992
Name:BUSTAMANTE, DANIELA E (MOT)
Entity Type:Individual
Prefix:
First Name:DANIELA
Middle Name:E
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19800 SEDGEFIELD TER
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33498-4734
Mailing Address - Country:US
Mailing Address - Phone:561-654-3130
Mailing Address - Fax:
Practice Address - Street 1:917 7TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2601
Practice Address - Country:US
Practice Address - Phone:561-414-3717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18842225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist