Healthcare Provider Details

I. General information

NPI: 1063293462
Provider Name (Legal Business Name): CLARENZ BUSTAMANTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CLARENZ BUSTAMANTE LPC

II. Dates (important events)

Enumeration Date: 10/11/2023
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10455 WHITE GRANITE DR
OAKTON VA
22124-2764
US

IV. Provider business mailing address

14807 ELMWOOD DR
WOODBRIDGE VA
22193-2620
US

V. Phone/Fax

Practice location:
  • Phone: 703-536-9000
  • Fax:
Mailing address:
  • Phone: 571-296-9799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701015990
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: