=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073127056
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BUSTAMANTE COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2020
-----------------------------------------------------
Last Update Date | 09/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 317 W HILL ST STE 203B
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30030-4368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-991-1619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5235 DEERLAKE DR
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30005-3604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-991-1619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LINDSEY BUSTAMANTE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 470-991-1619
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------