Provider Demographics
NPI:1720155799
Name:BASTA, MICHAEL P (MSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:P
Last Name:BASTA
Suffix:
Gender:M
Credentials:MSW
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 957
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLEN
Mailing Address - State:CA
Mailing Address - Zip Code:95442-0957
Mailing Address - Country:US
Mailing Address - Phone:707-935-6739
Mailing Address - Fax:
Practice Address - Street 1:793 1ST ST W
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-7036
Practice Address - Country:US
Practice Address - Phone:707-935-6739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS129671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical