Provider Demographics
NPI:1366123978
Name:LOPEZ BUSTOS, RICHARD (MS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:LOPEZ BUSTOS
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 N RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-8122
Mailing Address - Country:US
Mailing Address - Phone:575-343-2991
Mailing Address - Fax:
Practice Address - Street 1:1804 W TANSILL ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3796
Practice Address - Country:US
Practice Address - Phone:408-966-0942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSLPCF23032235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist