Provider Demographics
NPI:1205679735
Name:BUSTAMANTE, AUDREY LEE
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:LEE
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 PINE ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-4036
Mailing Address - Country:US
Mailing Address - Phone:719-415-1970
Mailing Address - Fax:
Practice Address - Street 1:201 LAMKIN ST APT 101
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3558
Practice Address - Country:US
Practice Address - Phone:719-543-6633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool