Provider Demographics
NPI:1588149009
Name:BASTFIELD, LARRY
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:BASTFIELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5404 REISTERSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-4403
Mailing Address - Country:US
Mailing Address - Phone:410-764-0590
Mailing Address - Fax:410-764-8519
Practice Address - Street 1:5404 REISTERSTOWN RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-4403
Practice Address - Country:US
Practice Address - Phone:410-764-0590
Practice Address - Fax:410-764-8519
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD30-0785651Medicaid
30-0785651OtherPREVENTATIVE SERVICES