Provider Demographics
NPI:1184616518
Name:BASTEN, MICHAEL L (PT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:L
Last Name:BASTEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14834 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85045-0468
Mailing Address - Country:US
Mailing Address - Phone:480-496-0498
Mailing Address - Fax:
Practice Address - Street 1:15410 S MOUNTAIN PKWY
Practice Address - Street 2:SUITE 112
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-6691
Practice Address - Country:US
Practice Address - Phone:480-940-8299
Practice Address - Fax:480-704-0888
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1877225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist