Provider Demographics
NPI:1447292818
Name:BUSTOS, SHAWN TYLER (OT)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:TYLER
Last Name:BUSTOS
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8409 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-9211
Mailing Address - Country:US
Mailing Address - Phone:405-616-0113
Mailing Address - Fax:405-616-0116
Practice Address - Street 1:8409 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-9211
Practice Address - Country:US
Practice Address - Phone:405-616-0113
Practice Address - Fax:405-616-0116
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK782225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100631740BMedicaid
OK100631740BMedicaid