Provider Demographics
NPI:1619609211
Name:BUSTOS, HANNAH THERESA
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:THERESA
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3955 PASEO DEL MAR DR
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-7483
Mailing Address - Country:US
Mailing Address - Phone:951-488-8088
Mailing Address - Fax:
Practice Address - Street 1:1918 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3439
Practice Address - Country:US
Practice Address - Phone:909-918-7223
Practice Address - Fax:909-610-1345
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician