Basic Information
| Provider Information | |||||||||
| NPI: | 1912558123 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSTAMANTE | ||||||||
| FirstName: | ISSAC | ||||||||
| MiddleName: | MANUEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 ENCINAL ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950602178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314691700 | ||||||||
| FaxNumber: | 8314251905 | ||||||||
| Practice Location | |||||||||
| Address1: | 5005 TEXAS ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921083723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196920727 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2019 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | CA | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103TB0200X | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
No ID Information.