Provider Demographics
NPI:1598271066
Name:BUSTAMANTE, ELIO MATTHEW
Entity Type:Individual
Prefix:
First Name:ELIO
Middle Name:MATTHEW
Last Name:BUSTAMANTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 GIORDANO AVE
Mailing Address - Street 2:
Mailing Address - City:PARLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08859-4110
Mailing Address - Country:US
Mailing Address - Phone:401-309-9033
Mailing Address - Fax:
Practice Address - Street 1:1050 GALLOPING HILL RD STE 205
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-7980
Practice Address - Country:US
Practice Address - Phone:908-686-1505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral