Provider Demographics
NPI:1619176195
Name:BUSTILLOS, NOEMI CORREA (COTA/L)
Entity Type:Individual
Prefix:
First Name:NOEMI
Middle Name:CORREA
Last Name:BUSTILLOS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-5053
Mailing Address - Country:US
Mailing Address - Phone:505-556-2120
Mailing Address - Fax:505-556-2190
Practice Address - Street 1:3025 TERRACE DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5053
Practice Address - Country:US
Practice Address - Phone:505-556-2120
Practice Address - Fax:505-556-2190
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1620224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant