Healthcare Provider Details

I. General information

NPI: 1922556265
Provider Name (Legal Business Name): SALAH BUSTAMI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 REMSEN ST 10TH FLOOR
BROOKLYN NY
11201-4333
US

IV. Provider business mailing address

57 W 58TH ST APT. 3E
NEW YORK NY
10019-1630
US

V. Phone/Fax

Practice location:
  • Phone: 718-852-5552
  • Fax:
Mailing address:
  • Phone: 646-255-7040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number007445
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: