Provider Demographics
NPI:1902402795
Name:BASTULLI, CHERYL
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:
Last Name:BASTULLI
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 1:1135 E 346TH ST
Mailing Address - Street 2:
Mailing Address - City:EASTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44095-2947
Mailing Address - Country:US
Mailing Address - Phone:440-669-0640
Mailing Address - Fax:
Practice Address - Street 1:1135 E 346TH ST
Practice Address - Street 2:
Practice Address - City:EASTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44095-2947
Practice Address - Country:US
Practice Address - Phone:440-669-0640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH274348172A00000X, 261QA0600X, 343900000X, 347C00000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No172A00000XOther Service ProvidersDriver
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle