Provider Demographics
NPI:1326182643
Name:BASTOW, CARRIE ELIZABETH
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ELIZABETH
Last Name:BASTOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:ELIZABETH
Other - Last Name:NESTOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4021 W 12TH ST OFC 3
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-3354
Mailing Address - Country:US
Mailing Address - Phone:814-806-4474
Mailing Address - Fax:
Practice Address - Street 1:4021 W 12TH ST OFC 3
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-3354
Practice Address - Country:US
Practice Address - Phone:814-806-4474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004300101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
251317492OtherVANTAGE