Provider Demographics
NPI:1245259548
Name:BASTEDO, DEBORAH A (LLP, LPC, NCC)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:BASTEDO
Suffix:
Gender:F
Credentials:LLP, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1069 PELHAM BLVD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-4262
Mailing Address - Country:US
Mailing Address - Phone:248-787-3916
Mailing Address - Fax:248-682-7486
Practice Address - Street 1:52188 VAN DYKE AVE
Practice Address - Street 2:STE 300
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-3567
Practice Address - Country:US
Practice Address - Phone:586-803-1583
Practice Address - Fax:248-682-7486
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011762103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI287751OtherMHN
MI2544866D1AOtherTRICARE