Provider Demographics
NPI:1568513794
Name:BASTIN, DAN E (LISW, ACSW)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:E
Last Name:BASTIN
Suffix:
Gender:M
Credentials:LISW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 BETHEL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-2003
Mailing Address - Country:US
Mailing Address - Phone:614-442-0664
Mailing Address - Fax:
Practice Address - Street 1:1555 BETHEL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-2003
Practice Address - Country:US
Practice Address - Phone:614-442-0664
Practice Address - Fax:614-442-0620
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-00003781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBASW26731Medicare ID - Type Unspecified