Basic Information
| Provider Information | |||||||||
| NPI: | 1164544128 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSTAMANTE | ||||||||
| FirstName: | PEDRO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1506 AMELIA DR | ||||||||
| Address2: | |||||||||
| City: | CEDAR PARK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786133218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123368682 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 701 E UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786267035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128639208 | ||||||||
| FaxNumber: | 5128647238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S35300 | TX | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.