Basic Information
| Provider Information | |||||||||
| NPI: | 1265575781 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASTAJIAN | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3533 | ||||||||
| Address2: | |||||||||
| City: | CRESTLINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923253533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093384113 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 820 E GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924150002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093877793 | ||||||||
| FaxNumber: | 9093870593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC25259 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.