Healthcare Provider Details

I. General information

NPI: 1720804958
Provider Name (Legal Business Name): MAYRA BUSTAMANTE CO61586344
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 SUPERIOR LN
YAKIMA WA
98902-1623
US

IV. Provider business mailing address

613 SUPERIOR LN
YAKIMA WA
98902-1623
US

V. Phone/Fax

Practice location:
  • Phone: 509-853-4151
  • Fax:
Mailing address:
  • Phone: 509-853-4151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61586344
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier91-0755984
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: