Provider Demographics
NPI:1285801654
Name:BASTOW, LAURA MARIE (LMHC, MS)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MARIE
Last Name:BASTOW
Suffix:
Gender:F
Credentials:LMHC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 N BEACH ST
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-3314
Mailing Address - Country:US
Mailing Address - Phone:386-562-0216
Mailing Address - Fax:
Practice Address - Street 1:160 N BEACH ST
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-3314
Practice Address - Country:US
Practice Address - Phone:386-562-0216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 8973101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health