Basic Information
| Provider Information | |||||||||
| NPI: | 1619405214 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSTAMANTE | ||||||||
| FirstName: | ELLEN | ||||||||
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| Credential: | MA, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6131 ANDOVER WOOD RD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891131882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149284009 | ||||||||
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| Practice Location | |||||||||
| Address1: | 255 E BONITA AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917671923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095967733 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2017 | ||||||||
| LastUpdateDate: | 11/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 22155 | CA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 2254 | NV | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 22155 | 01 | CA | SLP STATE LICENSE | OTHER |