Healthcare Provider Details

I. General information

NPI: 1871007138
Provider Name (Legal Business Name): LAURISSA BUSTILLOS MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2017
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 CAMINO ENTRADA
SANTA FE NM
87507-4851
US

IV. Provider business mailing address

5207 VIA DEL SOL
SANTA FE NM
87507-3638
US

V. Phone/Fax

Practice location:
  • Phone: 505-471-4985
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT-0193001
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: