Provider Demographics
NPI:1720804958
Name:BUSTAMANTE, MAYRA (CO61586344)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:CO61586344
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 SUPERIOR LN
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-1623
Mailing Address - Country:US
Mailing Address - Phone:509-853-4151
Mailing Address - Fax:
Practice Address - Street 1:613 SUPERIOR LN
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-1623
Practice Address - Country:US
Practice Address - Phone:509-853-4151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61586344101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-0755984Medicaid