Provider Demographics
NPI:1013286152
Name:BASTIAN, LESLIE T (AT,C)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:T
Last Name:BASTIAN
Suffix:
Gender:F
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 E 1100 S
Mailing Address - Street 2:
Mailing Address - City:MAPLETON
Mailing Address - State:UT
Mailing Address - Zip Code:84664-5012
Mailing Address - Country:US
Mailing Address - Phone:801-491-2199
Mailing Address - Fax:
Practice Address - Street 1:366 E 1100 S
Practice Address - Street 2:
Practice Address - City:MAPLETON
Practice Address - State:UT
Practice Address - Zip Code:84664-5012
Practice Address - Country:US
Practice Address - Phone:801-491-2199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT22OtherPROVIDER CODE