Provider Demographics
NPI:1063308609
Name:BUSTAMANTE, IBETTE MILENA
Entity type:Individual
Prefix:
First Name:IBETTE
Middle Name:MILENA
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 1:20107 GLEN BURN CT
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77346-2195
Mailing Address - Country:US
Mailing Address - Phone:832-712-9005
Mailing Address - Fax:
Practice Address - Street 1:20107 GLEN BURN CT
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77346-2195
Practice Address - Country:US
Practice Address - Phone:832-712-9005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-17
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX96895101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional