Provider Demographics
NPI:1851901714
Name:BUSTOS-GUTIERREZ, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:BUSTOS-GUTIERREZ
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 1:242 N VILLA AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOWS
Mailing Address - State:CA
Mailing Address - Zip Code:95988-2641
Mailing Address - Country:US
Mailing Address - Phone:530-865-6459
Mailing Address - Fax:
Practice Address - Street 1:604 E WALKER ST
Practice Address - Street 2:
Practice Address - City:ORLAND
Practice Address - State:CA
Practice Address - Zip Code:95963-2203
Practice Address - Country:US
Practice Address - Phone:530-865-6459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician