Provider Demographics
NPI:1265858179
Name:DIAZ-BASTIN, SARAH (CMT)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:DIAZ-BASTIN
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 FREDERICK ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2203
Mailing Address - Country:US
Mailing Address - Phone:831-239-5964
Mailing Address - Fax:
Practice Address - Street 1:626 FREDERICK ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2203
Practice Address - Country:US
Practice Address - Phone:831-239-5964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-16
Last Update Date:2014-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42349225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist