Healthcare Provider Details

I. General information

NPI: 1619456126
Provider Name (Legal Business Name): DULCE A MEDINA BUSTILLOS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7520 MONTGOMERY BLVD NE BLDG E15
ALBUQUERQUE NM
87109-1586
US

IV. Provider business mailing address

1519 SEVEN FALLS PL SW
ALBUQUERQUE NM
87121-3560
US

V. Phone/Fax

Practice location:
  • Phone: 505-226-6380
  • Fax: 505-214-5852
Mailing address:
  • Phone: 505-433-1993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2023-0147
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: