=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588907406
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. JUAN CARLOS BUSTOS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2013
-----------------------------------------------------
Last Update Date | 01/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 S DE LACEY AVE STE 110
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-395-7100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 S BEAUDRY AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90017-1466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-241-3841
-----------------------------------------------------
Fax | 213-241-3305
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW104590
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------