Provider Demographics
NPI:1053616474
Name:BUSTILLO, ANTONIO (PHD)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:
Last Name:BUSTILLO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 AVE PONCE DE LEON
Mailing Address - Street 2:SUITE 601-B HATO REY
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00917-4820
Mailing Address - Country:US
Mailing Address - Phone:787-518-1054
Mailing Address - Fax:787-750-1472
Practice Address - Street 1:623 AVE PONCE DE LEON
Practice Address - Street 2:SUITE 601-B HATO REY
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917-4820
Practice Address - Country:US
Practice Address - Phone:787-518-1054
Practice Address - Fax:787-750-1472
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-15
Last Update Date:2011-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1205103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical