Provider Demographics
NPI:1396538781
Name:GOYENECHE, ANNA THERESA BUSTAMANTE (PTA)
Entity type:Individual
Prefix:MISS
First Name:ANNA THERESA
Middle Name:BUSTAMANTE
Last Name:GOYENECHE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1286 MATTOX RD APT 52
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94541-1200
Mailing Address - Country:US
Mailing Address - Phone:510-398-3407
Mailing Address - Fax:
Practice Address - Street 1:2800 BENEDICT DR
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-6840
Practice Address - Country:US
Practice Address - Phone:510-357-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA9770225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant