Healthcare Provider Details

I. General information

NPI: 1174417455
Provider Name (Legal Business Name): ZURYAH BUSTAMANTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 E GREENWAY RD STE 100
PHOENIX AZ
85032-4805
US

IV. Provider business mailing address

931 W MISSION LN
PHOENIX AZ
85021-3140
US

V. Phone/Fax

Practice location:
  • Phone: 480-336-3665
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW-21438
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: