Basic Information
| Provider Information | |||||||||
| NPI: | 1124795570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSTAMANTE-QUINTANA | ||||||||
| FirstName: | ITALIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2904 ARKANSAS BLVD | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718542536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707734655 | ||||||||
| FaxNumber: | 8707724650 | ||||||||
| Practice Location | |||||||||
| Address1: | 1312 W COLLIN RAYE DR | ||||||||
| Address2: | |||||||||
| City: | DE QUEEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718322135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707779051 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2021 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | PLMSW | AR | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | PLMSW | AR | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.