Healthcare Provider Details

I. General information

NPI: 1982668919
Provider Name (Legal Business Name): ANDRES BUSTAMANTE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 N KING ST
NORTHAMPTON MA
01060-1121
US

IV. Provider business mailing address

370 N KING ST
NORTHAMPTON MA
01060-1121
US

V. Phone/Fax

Practice location:
  • Phone: 413-320-4118
  • Fax: 888-289-5206
Mailing address:
  • Phone: 413-320-4118
  • Fax: 888-289-5206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number8148
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: