Provider Demographics
NPI:1609445766
Name:BASTIEN, SAMUEL A IV (PHD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:A
Last Name:BASTIEN
Suffix:IV
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4061 FLINT CT
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-2598
Mailing Address - Country:US
Mailing Address - Phone:315-261-9862
Mailing Address - Fax:
Practice Address - Street 1:135 S BROADWAY
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-4532
Practice Address - Country:US
Practice Address - Phone:518-584-9030
Practice Address - Fax:518-581-1709
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009639-01103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical