Provider Demographics
NPI:1639270929
Name:BUSTAMANTE, MIGUEL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78221-3117
Mailing Address - Country:US
Mailing Address - Phone:210-334-3700
Mailing Address - Fax:210-922-0462
Practice Address - Street 1:3750 COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78221-3117
Practice Address - Country:US
Practice Address - Phone:210-334-3780
Practice Address - Fax:210-334-3786
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0057731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80419WOtherBCBS
TX037137901Medicaid
TX80419WOtherBCBS
TXTXB113761Medicare PIN
TX80419WMedicare PIN