Healthcare Provider Details

I. General information

NPI: 1851018162
Provider Name (Legal Business Name): CHRIS BUSTOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 CHERRY LN STE 208
MANTECA CA
95337-4311
US

IV. Provider business mailing address

302 CHERRY LN STE 208
MANTECA CA
95337-4311
US

V. Phone/Fax

Practice location:
  • Phone: 209-647-6200
  • Fax: 209-647-6210
Mailing address:
  • Phone: 209-647-6200
  • Fax: 209-647-6210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number101YM0800X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: