Provider Demographics
NPI:1700299336
Name:MEDINA-BUSTILLOS, DALIA M (MSW)
Entity Type:Individual
Prefix:MISS
First Name:DALIA
Middle Name:M
Last Name:MEDINA-BUSTILLOS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 57TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-1343
Mailing Address - Country:US
Mailing Address - Phone:505-267-7031
Mailing Address - Fax:
Practice Address - Street 1:701 57TH ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-1343
Practice Address - Country:US
Practice Address - Phone:505-267-7031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1700299336.Medicaid