Provider Demographics
NPI:1760535678
Name:PEREZ-BUSTILLO, ESTELA CECILIA (LICSW)
Entity Type:Individual
Prefix:
First Name:ESTELA
Middle Name:CECILIA
Last Name:PEREZ-BUSTILLO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 WYVERN ST
Mailing Address - Street 2:APT 2
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-2131
Mailing Address - Country:US
Mailing Address - Phone:617-522-3626
Mailing Address - Fax:
Practice Address - Street 1:150 MARKET ST
Practice Address - Street 2:2ND FL.
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1529
Practice Address - Country:US
Practice Address - Phone:781-592-6100
Practice Address - Fax:781-592-1093
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10299881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1893084Medicaid
MAP08641Medicare ID - Type Unspecified