Provider Demographics
NPI:1598288763
Name:BUSTAMANTE, RODELEINE M. SALVATUS (COTA)
Entity Type:Individual
Prefix:
First Name:RODELEINE M.
Middle Name:SALVATUS
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 E CHANDLER BLVD APT 1015
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7658
Mailing Address - Country:US
Mailing Address - Phone:520-229-7767
Mailing Address - Fax:
Practice Address - Street 1:1555 S GILBERT RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6000
Practice Address - Country:US
Practice Address - Phone:623-850-8420
Practice Address - Fax:844-273-5997
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ387105224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty