Provider Demographics
NPI:1356585483
Name:BASTA, DANIEL (PT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:BASTA
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 1:566 S MCCASLIN BLVD UNIT 270316
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:CO
Mailing Address - Zip Code:80027-5249
Mailing Address - Country:US
Mailing Address - Phone:347-489-4533
Mailing Address - Fax:
Practice Address - Street 1:2600 S ROCK CREEK PKWY APT 21-101
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:CO
Practice Address - Zip Code:80027-4505
Practice Address - Country:US
Practice Address - Phone:303-919-2324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-20
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030617-1225100000X
FLPT27724225100000X
CO0015879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist