MEDICARE: VANESSA LUCIA BUSTILLO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184964579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANESSA LUCIA BUSTILLO

Provider Business Mailing Address
First Line	:	11420 N KENDALL DR STE 112
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33176-1039
Country	:	US
Telephone Number	:	305-279-1999
Fax Number	:	305-459-3270

Provider Business Practice Location Address
First Line	:	11420 N KENDALL DR STE 112
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33176-1039
Country	:	US
Telephone Number	:	305-279-1999
Fax Number	:	305-459-3270

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2013
Last Update Date	:	01/03/2019

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Directions to “ VANESSA LUCIA BUSTILLO ” Practice Location

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