Provider Demographics
NPI:1366123341
Name:BUSTOS, KASSANDRA (BCBA LBA)
Entity type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:BCBA LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12408 DESSAU RD APT 1108
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78754-2239
Mailing Address - Country:US
Mailing Address - Phone:956-789-5600
Mailing Address - Fax:
Practice Address - Street 1:15930 S GREAT OAKS DR
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-5800
Practice Address - Country:US
Practice Address - Phone:512-460-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6023103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst