Provider Demographics
NPI:1104160043
Name:BASTYR UNIVERSITY
Entity type:Organization
Organization Name:BASTYR UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MOIRA
Authorized Official - Middle Name:PYLE
Authorized Official - Last Name:FITZPATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, ND
Authorized Official - Phone:858-246-9701
Mailing Address - Street 1:4106 SORRENTO VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1407
Mailing Address - Country:US
Mailing Address - Phone:858-246-9730
Mailing Address - Fax:858-246-9710
Practice Address - Street 1:4106 SORRENTO VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1407
Practice Address - Country:US
Practice Address - Phone:858-246-9730
Practice Address - Fax:858-246-9710
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BASTYR UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11413103TC1900X
CAND-556175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty