Provider Demographics
NPI:1659007045
Name:BASTIEN-LARIVAUX, PERLA (LMFT-LPC)
Entity Type:Individual
Prefix:
First Name:PERLA
Middle Name:
Last Name:BASTIEN-LARIVAUX
Suffix:
Gender:F
Credentials:LMFT-LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 CHURCH ST REAR REAR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:NJ
Mailing Address - Zip Code:07644-2407
Mailing Address - Country:US
Mailing Address - Phone:862-591-0211
Mailing Address - Fax:
Practice Address - Street 1:56 CHURCH ST REAR REAR
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:NJ
Practice Address - Zip Code:07644-2407
Practice Address - Country:US
Practice Address - Phone:862-591-0211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00863400106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty