Provider Demographics
NPI:1679693709
Name:BUSTAMANTE, ANA LUISA (PHD)
Entity type:Individual
Prefix:DR
First Name:ANA
Middle Name:LUISA
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17550 W DESERT SAGE DR
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-5756
Mailing Address - Country:US
Mailing Address - Phone:602-418-2049
Mailing Address - Fax:
Practice Address - Street 1:17550 W DESERT SAGE DR
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-5756
Practice Address - Country:US
Practice Address - Phone:602-418-2049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1037103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist