Provider Demographics
NPI:1922230671
Name:BASTIAANSE, MATTHEW J (LMFT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:J
Last Name:BASTIAANSE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 WINDHAM RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010
Mailing Address - Country:US
Mailing Address - Phone:860-261-5367
Mailing Address - Fax:860-261-5367
Practice Address - Street 1:29 WINDHAM RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010
Practice Address - Country:US
Practice Address - Phone:860-261-5367
Practice Address - Fax:860-261-5367
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-13
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001281106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist