Provider Demographics
NPI:1174075667
Name:BUSTIN, IRINA
Entity type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:BUSTIN
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 1:1200 W 35TH ST STE 5B5220
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-1305
Mailing Address - Country:US
Mailing Address - Phone:312-800-1767
Mailing Address - Fax:
Practice Address - Street 1:1200 W 35TH ST STE 5B5220
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-1305
Practice Address - Country:US
Practice Address - Phone:312-800-1767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health