Provider Demographics
NPI:1356636112
Name:BASTIEN, JAMES S (LICSW, MHD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:S
Last Name:BASTIEN
Suffix:
Gender:M
Credentials:LICSW, MHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 S PLAIN RD
Mailing Address - Street 2:
Mailing Address - City:SUNDERLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01375-9469
Mailing Address - Country:US
Mailing Address - Phone:413-687-7844
Mailing Address - Fax:
Practice Address - Street 1:421 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LEEDS
Practice Address - State:MA
Practice Address - Zip Code:01053-9764
Practice Address - Country:US
Practice Address - Phone:413-548-4040
Practice Address - Fax:413-582-3073
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
MA1164071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst