Provider Demographics
NPI:1982421442
Name:BUSTOS, ALLEN
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:
Last Name:BUSTOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E BELLEVUE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-2305
Mailing Address - Country:US
Mailing Address - Phone:650-343-8401
Mailing Address - Fax:
Practice Address - Street 1:202 E BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2305
Practice Address - Country:US
Practice Address - Phone:650-343-8401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
19030101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty