Provider Demographics
NPI:1225472285
Name:BASTINELLI, DOMINIC MICHAEL (LSCSW)
Entity Type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:MICHAEL
Last Name:BASTINELLI
Suffix:
Gender:M
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 S 4TH ST
Mailing Address - Street 2:BLDG 160
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-5014
Mailing Address - Country:US
Mailing Address - Phone:913-682-2000
Mailing Address - Fax:913-758-4149
Practice Address - Street 1:4101 S 4TH ST
Practice Address - Street 2:BLDG 160
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-5014
Practice Address - Country:US
Practice Address - Phone:913-682-2000
Practice Address - Fax:913-758-4149
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical