Provider Demographics
NPI:1316453061
Name:BASTIA, MALGORZATA
Entity type:Individual
Prefix:
First Name:MALGORZATA
Middle Name:
Last Name:BASTIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 ATKINSON RD STE 1100
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7986
Mailing Address - Country:US
Mailing Address - Phone:770-995-2379
Mailing Address - Fax:770-995-2385
Practice Address - Street 1:1509 ATKINSON RD STE 1100
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-7986
Practice Address - Country:US
Practice Address - Phone:770-995-2379
Practice Address - Fax:770-995-2385
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006917225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist