Provider Demographics
NPI:1649035460
Name:BASTIAN, BARRY WARREN (MA, MS)
Entity type:Individual
Prefix:MR
First Name:BARRY
Middle Name:WARREN
Last Name:BASTIAN
Suffix:
Gender:M
Credentials:MA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 4TH ST # 5019
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4057
Mailing Address - Country:US
Mailing Address - Phone:415-707-7838
Mailing Address - Fax:
Practice Address - Street 1:390 CAHILL LN
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5554
Practice Address - Country:US
Practice Address - Phone:415-707-7838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT43040106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist