MEDICARE: KATELYN RENEE BUSTILLOS

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	224Z00000X	Occupational Therapy Assistant	215482	TX

General Provider Information

NPI Number	:	1811844616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATELYN RENEE BUSTILLOS

Provider Business Mailing Address
First Line	:	2926 W ROYAL LN APT 3102
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75063-5746
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	355 W WESTCHESTER PKWY
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-5284
Country	:	US
Telephone Number	:	972-263-3663
Fax Number	:

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

Provider Enumeration Date	:	03/12/2026
Last Update Date	:	03/12/2026

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