Provider Demographics
NPI:1841343613
Name:BASTEK, SUSANNAH COBURN (LICSW)
Entity type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:COBURN
Last Name:BASTEK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01062-1346
Mailing Address - Country:US
Mailing Address - Phone:413-303-9819
Mailing Address - Fax:
Practice Address - Street 1:129 KING ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3258
Practice Address - Country:US
Practice Address - Phone:413-586-0390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1137281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical