Basic Information
| Provider Information | |||||||||
| NPI: | 1417068321 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASTIDAS | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | FISHER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | SSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 750 NORTH 200 WEST | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013734760 | ||||||||
| FaxNumber: | 8013730639 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 NORTH 200 WEST | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013734760 | ||||||||
| FaxNumber: | 8013730639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 333885 3503 | UT | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.