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General NPI Number Information
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NPI Number | 1558670976
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Entity Type | Individual
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Provider Name | GASTON LUIS BUSTOS PH.D., LMHC
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Gender | Male
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Dates
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Enumeration Date | 10/04/2010
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Last Update Date | 10/04/2010
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Provider Practice Location Address
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Address Line | 3521 W BROWARD BLVD FL 3
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City | FORT LAUDERDALE
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State | FL
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Zip | 33312-1048
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Country | US
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Telephone | 954-587-1008
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Fax |
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Provider Business Mailing Address
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Address Line | 4212 VAN BUREN ST
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City | HOLLYWOOD
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State | FL
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Zip | 33021-7236
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Country | US
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Telephone | 954-966-9448
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH 9213
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License Number State | FL
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