Healthcare Provider Details

I. General information

NPI: 1003423484
Provider Name (Legal Business Name): MELISSA BUSTILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 CENTERPOINTE CIR STE 1301
ALTAMONTE SPRINGS FL
32701-3443
US

IV. Provider business mailing address

8673 REYMONT ST
ORLANDO FL
32827-7538
US

V. Phone/Fax

Practice location:
  • Phone: 800-509-3090
  • Fax:
Mailing address:
  • Phone: 786-302-2276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: