Provider Demographics
NPI:1225322936
Name:BUSTOS DE WEAVER, BRENDA LOURDES (LGSW)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:LOURDES
Last Name:BUSTOS DE WEAVER
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:LOURDES
Other - Last Name:BUSTOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LGSW
Mailing Address - Street 1:1609 COUNTY ROAD 42 W STE 309
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-6213
Mailing Address - Country:US
Mailing Address - Phone:918-896-3604
Mailing Address - Fax:
Practice Address - Street 1:1609 COUNTY ROAD 42 W STE 309
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-6213
Practice Address - Country:US
Practice Address - Phone:918-896-3604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2025-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN351021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746170GMedicaid