MEDICARE: MRS. ADRIANA MARIA BUSTAMANTE-CONWAY MED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	915	NE
2	101YP2500X	Professional Counselor	1828	NE
3	101Y00000X	Counselor	3666	NE

General Provider Information

NPI Number	:	1184832016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ADRIANA MARIA BUSTAMANTE-CONWAY MED

Provider Business Mailing Address
First Line	:	4920 S 30TH ST STE 103
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68107-1656
Country	:	US
Telephone Number	:	402-734-4110
Fax Number	:	402-991-5642

Provider Business Practice Location Address
First Line	:	4920 S 30TH ST STE 103
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68107-1656
Country	:	US
Telephone Number	:	402-734-4110
Fax Number	:	402-991-5642

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	10/12/2011

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Directions to “ MRS. ADRIANA MARIA BUSTAMANTE-CONWAY MED” Practice Location

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