Provider Demographics
NPI:1104171222
Name:BUSTOS, YANINE MARIEL (MA)
Entity type:Individual
Prefix:
First Name:YANINE
Middle Name:MARIEL
Last Name:BUSTOS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 W 130TH ST
Mailing Address - Street 2:APT. 6
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-1755
Mailing Address - Country:US
Mailing Address - Phone:626-827-6634
Mailing Address - Fax:
Practice Address - Street 1:855 W 130TH ST
Practice Address - Street 2:APT. 6
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-1755
Practice Address - Country:US
Practice Address - Phone:626-827-6634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-14
Last Update Date:2012-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor