Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst | ||
N | 103K00000X | Behavior Analyst | TX |
NPI | 1003307851 |
---|---|
Provider Name | Alexia Elissa Bustamante |
First Address | Woodland Hills, CA 91367-7807 |
Second Address | Salem, OR 97301-7012 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/05/2018 |
Last Update Date | 27/05/2018 |