Healthcare Provider Details

I. General information

NPI: 1679494553
Provider Name (Legal Business Name): DAVID BUSTAMANTE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16501 ANNAPOLIS RD
BOWIE MD
20715-3008
US

IV. Provider business mailing address

11001 HIDDEN FOX CT
ELLICOTT CITY MD
21042-6124
US

V. Phone/Fax

Practice location:
  • Phone: 202-415-7600
  • Fax:
Mailing address:
  • Phone: 202-415-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP16409
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: