1174727283 NPI number — MRS. STACY ELIZABETH BASTIN MA CCC SLP

Table of content: MRS. STACY ELIZABETH BASTIN MA CCC SLP (NPI 1174727283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174727283 NPI number — MRS. STACY ELIZABETH BASTIN MA CCC SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASTIN
Provider First Name:
STACY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA CCC SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DRAKE
Provider Other First Name:
STACY
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA CCC SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174727283
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
765 BRIGHTRIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRIDGEPORT
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26330-1172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-844-0099
Provider Business Mailing Address Fax Number:
304-848-0265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
765 BRIGHTRIDGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26330-1172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-844-0099
Provider Business Practice Location Address Fax Number:
304-848-0265
Provider Enumeration Date:
06/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP 0710 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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