Healthcare Provider Details

I. General information

NPI: 1164544128
Provider Name (Legal Business Name): PEDRO BUSTAMANTE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E UNIVERSITY AVE
GEORGETOWN TX
78626-7035
US

IV. Provider business mailing address

1506 AMELIA DR
CEDAR PARK TX
78613-3218
US

V. Phone/Fax

Practice location:
  • Phone: 512-863-9208
  • Fax: 512-864-7238
Mailing address:
  • Phone: 512-336-8682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS35300
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: