Provider Demographics
NPI:1861367534
Name:BASTIDA, MOLLY (AUD CCC-A)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:BASTIDA
Suffix:
Gender:F
Credentials:AUD CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15009 CATLIN TILTON RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61833-4776
Mailing Address - Country:US
Mailing Address - Phone:217-443-8273
Mailing Address - Fax:
Practice Address - Street 1:15009 CATLIN TILTON RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61833-4776
Practice Address - Country:US
Practice Address - Phone:217-443-8273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-10
Last Update Date:2025-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147.002055231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist