Provider Demographics
NPI:1225607880
Name:BASTA, GLORIA
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:BASTA
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 1:435 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:FOREST CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50436-1948
Mailing Address - Country:US
Mailing Address - Phone:641-420-1280
Mailing Address - Fax:
Practice Address - Street 1:606 S 7TH ST
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:IA
Practice Address - Zip Code:50436-2032
Practice Address - Country:US
Practice Address - Phone:641-585-2232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA107453235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist