Provider Demographics
NPI:1386118933
Name:DE LOS RIOS BUSTILLOS, XIMENA
Entity type:Individual
Prefix:
First Name:XIMENA
Middle Name:
Last Name:DE LOS RIOS BUSTILLOS
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 1:7325 RIO DEL SOL
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-7315
Mailing Address - Country:US
Mailing Address - Phone:505-490-9310
Mailing Address - Fax:
Practice Address - Street 1:4001 OFFICE COURT DR STE 706
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4958
Practice Address - Country:US
Practice Address - Phone:505-490-9310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM515265180106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician