Provider Demographics
NPI:1467005413
Name:BAST, SIDNEY ANNE (OTR/L)
Entity Type:Individual
Prefix:
First Name:SIDNEY
Middle Name:ANNE
Last Name:BAST
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38967 LONE CIR
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-6201
Mailing Address - Country:US
Mailing Address - Phone:951-264-0534
Mailing Address - Fax:
Practice Address - Street 1:24671 MONROE AVE STE 101
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-2527
Practice Address - Country:US
Practice Address - Phone:951-677-4105
Practice Address - Fax:951-677-4106
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20077225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist