Provider Demographics
NPI:1972118875
Name:BUSTOS ALFONSO, NATHALY ANDREA
Entity type:Individual
Prefix:
First Name:NATHALY
Middle Name:ANDREA
Last Name:BUSTOS ALFONSO
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 1:19169 ROMAN WAY
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-5064
Mailing Address - Country:US
Mailing Address - Phone:617-803-1485
Mailing Address - Fax:
Practice Address - Street 1:2921 STRANDEN RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-2941
Practice Address - Country:US
Practice Address - Phone:617-803-1485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty