Provider Demographics
NPI:1316198336
Name:BASTIDA, WENDY MICHELLE (BACHELORS OF SCIENCE)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:MICHELLE
Last Name:BASTIDA
Suffix:
Gender:F
Credentials:BACHELORS OF SCIENCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11153 STAGG ST
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352-4494
Mailing Address - Country:US
Mailing Address - Phone:818-764-2496
Mailing Address - Fax:
Practice Address - Street 1:237 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2531
Practice Address - Country:US
Practice Address - Phone:818-547-9544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator