Provider Demographics
NPI:1558582502
Name:BUSTAMANTE, MARIA (SOCIAL WORKER)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:SOCIAL WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 HASKELL ST.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107
Mailing Address - Country:US
Mailing Address - Phone:817-377-4011
Mailing Address - Fax:817-377-9269
Practice Address - Street 1:1051 HASKELL ST.
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107
Practice Address - Country:US
Practice Address - Phone:817-377-4011
Practice Address - Fax:817-377-9269
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20442104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX20442OtherLICENSE NUMBER