Provider Demographics
NPI:1285341339
Name:BUSTAMANTE ELY, CARMEN JUDITH
Entity type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:JUDITH
Last Name:BUSTAMANTE ELY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:JUDITH
Other - Last Name:BUSTAMANTE RAMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3702 RUFFIN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1893
Mailing Address - Country:US
Mailing Address - Phone:619-297-4300
Mailing Address - Fax:
Practice Address - Street 1:3702 RUFFIN RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1893
Practice Address - Country:US
Practice Address - Phone:619-297-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-28
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-25-79306103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst