Provider Demographics
NPI:1780208454
Name:BAST, SHERRIE
Entity Type:Individual
Prefix:
First Name:SHERRIE
Middle Name:
Last Name:BAST
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 1:117 S LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34788-2680
Mailing Address - Country:US
Mailing Address - Phone:352-874-1610
Mailing Address - Fax:
Practice Address - Street 1:117 S LAKE DR
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788-2680
Practice Address - Country:US
Practice Address - Phone:352-874-1610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW172861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical