Provider Demographics
NPI:1124294533
Name:BUSTAMANTE, KIM M (CADC II, QMHA)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:M
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:CADC II, QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3321 HAROLD DR NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1339
Mailing Address - Country:US
Mailing Address - Phone:503-363-2021
Mailing Address - Fax:503-363-4820
Practice Address - Street 1:3321 HAROLD DRIVE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305
Practice Address - Country:US
Practice Address - Phone:503-363-2021
Practice Address - Fax:503-363-4820
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X, 171M00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator