Provider Demographics
NPI:1649678863
Name:BUSTOS, STACY RAYANN (OTR)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:RAYANN
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 ASHWOOD S
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-5595
Mailing Address - Country:US
Mailing Address - Phone:281-851-3086
Mailing Address - Fax:
Practice Address - Street 1:132 ASHWOOD S
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-5595
Practice Address - Country:US
Practice Address - Phone:281-851-3086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11319225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist