Basic Information
| Provider Information | |||||||||
| NPI: | 1891031217 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAST | ||||||||
| FirstName: | ANDREA | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 417147 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022417147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189528140 | ||||||||
| FaxNumber: | 5189528287 | ||||||||
| Practice Location | |||||||||
| Address1: | 8002 KEW GARDENS RD | ||||||||
| Address2: | SUITE 704 | ||||||||
| City: | KEW GARDENS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114153600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185201513 | ||||||||
| FaxNumber: | 7185206460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2012 | ||||||||
| LastUpdateDate: | 12/13/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 5765891 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 03008151 | 05 | NY | MEDICAID |