Provider Demographics
NPI:1457832594
Name:BASTIAN, MONICA LYNN (PT)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:LYNN
Last Name:BASTIAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:507 NE 47TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2236
Practice Address - Country:US
Practice Address - Phone:503-215-6488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6233225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist