Provider Demographics
NPI:1013924042
Name:SANDOVAL BUSTAMANTE, MARTHA LETICIA (LCSW)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:LETICIA
Last Name:SANDOVAL BUSTAMANTE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:L
Other - Last Name:BUSTAMANTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:36000 DARNALL LOOP
Mailing Address - Street 2:CARL R DARNALL ARMY MEDICAL CENTER
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544
Mailing Address - Country:US
Mailing Address - Phone:254-288-6474
Mailing Address - Fax:
Practice Address - Street 1:BUILDING 2255
Practice Address - Street 2:DEPARTMENT OF SOCIAL WORK
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-288-6474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX286511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical