Provider Demographics
NPI:1174727283
Name:BASTIN, STACY ELIZABETH (MA CCC SLP)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:ELIZABETH
Last Name:BASTIN
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:MISS
Other - First Name:STACY
Other - Middle Name:ELIZABETH
Other - Last Name:DRAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC SLP
Mailing Address - Street 1:765 BRIGHTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1172
Mailing Address - Country:US
Mailing Address - Phone:304-844-0099
Mailing Address - Fax:304-848-0265
Practice Address - Street 1:765 BRIGHTRIDGE DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1172
Practice Address - Country:US
Practice Address - Phone:304-844-0099
Practice Address - Fax:304-848-0265
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP 0710235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist