Provider Demographics
NPI:1992912422
Name:BASTY, MARIE ANNETTE (LICENSED CLINICAL SO)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ANNETTE
Last Name:BASTY
Suffix:
Gender:F
Credentials:LICENSED CLINICAL SO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13380 W TREPANIA ROAD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843
Mailing Address - Country:US
Mailing Address - Phone:715-497-0790
Mailing Address - Fax:
Practice Address - Street 1:LAC COURTE OREILLES COMMUNITY HEALTH CENTER
Practice Address - Street 2:13380 W TREPANIA ROAD
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843
Practice Address - Country:US
Practice Address - Phone:715-638-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1271761041C0700X
WI7686-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43716300Medicaid