Provider Demographics
NPI:1841589272
Name:BASTIAN, EMILY ANN (LICSW)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ANN
Last Name:BASTIAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-1939
Mailing Address - Country:US
Mailing Address - Phone:612-752-8236
Mailing Address - Fax:
Practice Address - Street 1:1825 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-1939
Practice Address - Country:US
Practice Address - Phone:612-752-8236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-06
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN181281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical