Provider Demographics
NPI:1023788650
Name:FASTRICH, SEBASTIAN BACH (LCSW, LMSW, MCAP)
Entity type:Individual
Prefix:MR
First Name:SEBASTIAN
Middle Name:BACH
Last Name:FASTRICH
Suffix:
Gender:M
Credentials:LCSW, LMSW, MCAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FORD PL STE 3A
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-4806
Mailing Address - Fax:
Practice Address - Street 1:6773 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3030
Practice Address - Country:US
Practice Address - Phone:248-788-3033
Practice Address - Fax:248-661-7347
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW218751041C0700X
MI68011197571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMCAP.0101133OtherMASTERS LEVEL CERTIFIED ADDICTION'S PROFESSIONAL
MI6801119757OtherSTATE LICENSE