Provider Demographics
NPI:1265575781
Name:BASTAJIAN, GARY EDWARD (MFT)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:EDWARD
Last Name:BASTAJIAN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3533
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-3533
Mailing Address - Country:US
Mailing Address - Phone:909-338-4113
Mailing Address - Fax:
Practice Address - Street 1:820 E GILBERT ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-0002
Practice Address - Country:US
Practice Address - Phone:909-387-7793
Practice Address - Fax:909-387-0593
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC25259106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist