=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093016420
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADRIANA ELISSA BUSTAMANTE LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2010
-----------------------------------------------------
Last Update Date | 11/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1003 JUSTIN LN APT 1077
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78757-2662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-203-2705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1003 JUSTIN LN APT 1077
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78757-2662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-203-2705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 41042
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------