Provider Demographics
NPI:1073045712
Name:BAST, MEGAN (CCLS)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:BAST
Suffix:
Gender:F
Credentials:CCLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 NE 125TH ST
Mailing Address - Street 2:APT 206
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-3970
Mailing Address - Country:US
Mailing Address - Phone:920-419-3780
Mailing Address - Fax:
Practice Address - Street 1:840 NE 125TH ST
Practice Address - Street 2:APT 206
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-3970
Practice Address - Country:US
Practice Address - Phone:920-419-3780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIB230-5589-4628-00106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician