Provider Demographics
NPI:1346816600
Name:MENJIVAR, BASTY A (MS)
Entity type:Individual
Prefix:
First Name:BASTY
Middle Name:A
Last Name:MENJIVAR
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 E EL SUR ST
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-4801
Mailing Address - Country:US
Mailing Address - Phone:626-861-6311
Mailing Address - Fax:
Practice Address - Street 1:1100 SPORTFISHER DR
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-2550
Practice Address - Country:US
Practice Address - Phone:760-439-6702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling