Provider Demographics
NPI:1558761205
Name:BUSTAMANTE, VALENTINA (ATC)
Entity Type:Individual
Prefix:
First Name:VALENTINA
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 DISTRICT DR
Mailing Address - Street 2:APT#2112A
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2887
Mailing Address - Country:US
Mailing Address - Phone:305-609-4315
Mailing Address - Fax:
Practice Address - Street 1:1993 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-9138
Practice Address - Country:US
Practice Address - Phone:305-609-4315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-31
Last Update Date:2014-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL33582255A2300X
WVAT0012722255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer