Provider Demographics
NPI:1285095042
Name:BUSTOS, ILENE M (MA, ATR-BC, LPC)
Entity type:Individual
Prefix:MRS
First Name:ILENE
Middle Name:M
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:MA, ATR-BC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 SEVEN BRIDGE RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-7937
Mailing Address - Country:US
Mailing Address - Phone:570-431-3005
Mailing Address - Fax:
Practice Address - Street 1:529 SEVEN BRIDGE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-7937
Practice Address - Country:US
Practice Address - Phone:570-431-3005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-08
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC008451101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health