Provider Demographics
NPI:1699324525
Name:BUSTAMANTES, DESIREE NICOLE (SCHOOL PSYCH INTERN)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:NICOLE
Last Name:BUSTAMANTES
Suffix:
Gender:F
Credentials:SCHOOL PSYCH INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 E POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-4807
Mailing Address - Country:US
Mailing Address - Phone:575-546-5951
Mailing Address - Fax:575-546-5994
Practice Address - Street 1:310 W ELM ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-4123
Practice Address - Country:US
Practice Address - Phone:575-546-0427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM393374103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool