Healthcare Provider Details

I. General information

NPI: 1588907406
Provider Name (Legal Business Name): MR. JUAN CARLOS BUSTOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S DE LACEY AVE STE 110
PASADENA CA
91105
US

IV. Provider business mailing address

333 S BEAUDRY AVE
LOS ANGELES CA
90017-1466
US

V. Phone/Fax

Practice location:
  • Phone: 626-395-7100
  • Fax:
Mailing address:
  • Phone: 213-241-3841
  • Fax: 213-241-3305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW104590
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: