Provider Demographics
NPI:1265208326
Name:LEBASTCHI, SHAYAN SHAWN
Entity type:Individual
Prefix:
First Name:SHAYAN
Middle Name:SHAWN
Last Name:LEBASTCHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 BEDFORD AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-2024
Mailing Address - Country:US
Mailing Address - Phone:858-336-6984
Mailing Address - Fax:
Practice Address - Street 1:203 BERRY ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11249-3114
Practice Address - Country:US
Practice Address - Phone:646-875-8348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048903-012251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic