Provider Demographics
NPI:1639778624
Name:GARCIA BUSTAMANTE, BERTA ALICIA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:BERTA
Middle Name:ALICIA
Last Name:GARCIA BUSTAMANTE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 UNION SQUARE WEST
Mailing Address - Street 2:FRONT 1, #1148
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003
Mailing Address - Country:US
Mailing Address - Phone:917-293-8494
Mailing Address - Fax:
Practice Address - Street 1:96 W HOUSTON ST STE 1F
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-2553
Practice Address - Country:US
Practice Address - Phone:929-265-1009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2023-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1100031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical