Provider Demographics
NPI:1740297266
Name:AVELLANEDA, VICTORIA BUSTAMANTE (PSYD)
Entity type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:BUSTAMANTE
Last Name:AVELLANEDA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 RIVIERA AVE
Mailing Address - Street 2:
Mailing Address - City:CLEWISTON
Mailing Address - State:FL
Mailing Address - Zip Code:33440-9043
Mailing Address - Country:US
Mailing Address - Phone:305-439-6014
Mailing Address - Fax:863-902-1512
Practice Address - Street 1:2100 RIVIERA AVE
Practice Address - Street 2:
Practice Address - City:CLEWISTON
Practice Address - State:FL
Practice Address - Zip Code:33440-9043
Practice Address - Country:US
Practice Address - Phone:305-439-6014
Practice Address - Fax:863-902-1512
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 5919103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0761575 00Medicaid
FL0761575 00Medicaid