Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | OT001387 | GA |
NPI | 1003039660 |
---|---|
Provider Name | Susana Bustos |
First Address | North Augusta, SC 29841-3632 |
Second Address | Waynesboro, GA 30830-9686 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2007 |
Last Update Date | 08/07/2007 |