Provider Demographics
NPI:1548752330
Name:BASTIEN, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BASTIEN
Suffix:
Gender:F
Credentials:
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 306393
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-6393
Mailing Address - Country:US
Mailing Address - Phone:615-373-1350
Mailing Address - Fax:615-221-9054
Practice Address - Street 1:2011 GRINSTEAD DR UNIT 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1296
Practice Address - Country:US
Practice Address - Phone:502-813-7838
Practice Address - Fax:502-813-7839
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007422225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist