Provider Demographics
NPI:1588409338
Name:BUSTAMANTE GUERRERO, SANDY YERALDIN
Entity type:Individual
Prefix:
First Name:SANDY YERALDIN
Middle Name:
Last Name:BUSTAMANTE GUERRERO
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 1:3370 BEAU RIVAGE DR APT R4
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-2041
Mailing Address - Country:US
Mailing Address - Phone:954-601-7272
Mailing Address - Fax:
Practice Address - Street 1:3370 BEAU RIVAGE DR APT R4
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-2041
Practice Address - Country:US
Practice Address - Phone:954-601-7272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-345166106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician