=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306343918
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE BUSTOS DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2018
-----------------------------------------------------
Last Update Date | 04/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 47461 US HIGHWAY 41
-----------------------------------------------------
City | HOUGHTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49931-9016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-285-6720
-----------------------------------------------------
Fax | 906-254-3554
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19045 WHITE PINE LN
-----------------------------------------------------
City | HOUGHTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49931-9066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-281-5544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5501015918
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------