Provider Demographics
NPI:1912046038
Name:BASTEDO, CHARLES EDGAR (MFCT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDGAR
Last Name:BASTEDO
Suffix:
Gender:M
Credentials:MFCT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5199 E PACIFIC COAST HWY
Mailing Address - Street 2:SUITE 504
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-3371
Mailing Address - Country:US
Mailing Address - Phone:562-498-1750
Mailing Address - Fax:562-498-7463
Practice Address - Street 1:5199 E PACIFIC COAST HWY
Practice Address - Street 2:SUITE 504
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-3371
Practice Address - Country:US
Practice Address - Phone:562-498-1750
Practice Address - Fax:562-498-7463
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15096106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist