Provider Demographics
NPI:1750426557
Name:BUSTAMANTE, DONNA G (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:G
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9644 W CLARA LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-5130
Mailing Address - Country:US
Mailing Address - Phone:623-322-6014
Mailing Address - Fax:
Practice Address - Street 1:4407 N 55TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-1802
Practice Address - Country:US
Practice Address - Phone:623-691-2341
Practice Address - Fax:623-691-4320
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP1577235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZSLP1577OtherAZ DEPART OF HEALTH SERVI