Provider Demographics
NPI:1639487374
Name:INOMAA-BUSTILLOS, ELISABETH
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:INOMAA-BUSTILLOS
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 1:29995 TECHNOLOGY DR STE 103
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-2633
Mailing Address - Country:US
Mailing Address - Phone:323-302-1564
Mailing Address - Fax:323-967-7081
Practice Address - Street 1:29995 TECHNOLOGY DR STE 103
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-2633
Practice Address - Country:US
Practice Address - Phone:323-302-1564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27017103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical