Provider Demographics
NPI:1366892283
Name:BUSTOS, ERICA (MA)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
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 1:805 S CASCADE AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-4101
Mailing Address - Country:US
Mailing Address - Phone:719-473-9200
Mailing Address - Fax:
Practice Address - Street 1:805 S CASCADE AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-4101
Practice Address - Country:US
Practice Address - Phone:719-473-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101YM0800X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health