Provider Demographics
NPI:1952628448
Name:BUSTOS, JUDITH
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JUDITH
Other - Middle Name:
Other - Last Name:RUBIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:350 ROSEBUD LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-7240
Mailing Address - Country:US
Mailing Address - Phone:619-208-1754
Mailing Address - Fax:
Practice Address - Street 1:835 3RD AVE STE C
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1352
Practice Address - Country:US
Practice Address - Phone:619-427-4661
Practice Address - Fax:619-426-7849
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$OtherSOCIAL SECURITY NUMBER