Provider Demographics
NPI:1700581394
Name:BUSTOS, VANESSA MARIE
Entity Type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:MARIE
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631A MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90014-2211
Mailing Address - Country:US
Mailing Address - Phone:213-561-1975
Mailing Address - Fax:
Practice Address - Street 1:631A MAPLE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90014-2211
Practice Address - Country:US
Practice Address - Phone:213-561-1975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFSDWILTCRGYQJOPU175T00000X
CAC25771214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist