Basic Information
| Provider Information | |||||||||
| NPI: | 1326583477 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VASTARDIS | ||||||||
| FirstName: | JASON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 AMERICAN AVE | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194064023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106446464 | ||||||||
| FaxNumber: | 6109816078 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 CHESLEY DR | ||||||||
| Address2: | #5 | ||||||||
| City: | MEDIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190631760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106446464 | ||||||||
| FaxNumber: | 6109816078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2016 | ||||||||
| LastUpdateDate: | 12/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | PC009008 | PA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.