Provider Demographics
NPI:1912663931
Name:BUSTAMANTE, JOANNA DELIA
Entity Type:Individual
Prefix:MS
First Name:JOANNA
Middle Name:DELIA
Last Name:BUSTAMANTE
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 1:1216 OLD MANOR RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846-4536
Mailing Address - Country:US
Mailing Address - Phone:620-640-0051
Mailing Address - Fax:
Practice Address - Street 1:1216 OLD MANOR RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846-4536
Practice Address - Country:US
Practice Address - Phone:620-640-0051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-14
Last Update Date:2021-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10245104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker