Provider Demographics
NPI:1104031285
Name:BASTIN, JUDITH MARIE
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:MARIE
Last Name:BASTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 D ST
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-2571
Mailing Address - Country:US
Mailing Address - Phone:925-754-3673
Mailing Address - Fax:925-754-2002
Practice Address - Street 1:1915 D ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-2571
Practice Address - Country:US
Practice Address - Phone:925-754-3673
Practice Address - Fax:925-754-2002
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0753OtherMEDI-CAL BILLING NUMBER
CA070753OtherMASTER PROVIDER NUMBER