Healthcare Provider Details

I. General information

NPI: 1003466731
Provider Name (Legal Business Name): JOSUE BUSTOS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2019
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 N CENTRAL AVE STE 200
PHOENIX AZ
85004-1844
US

IV. Provider business mailing address

1101 N CENTRAL AVE STE 200
PHOENIX AZ
85004-1844
US

V. Phone/Fax

Practice location:
  • Phone: 602-307-5330
  • Fax: 602-307-5021
Mailing address:
  • Phone: 602-307-5330
  • Fax: 602-307-5021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-17968
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: