Provider Demographics
NPI:1164864682
Name:BASTIEN, BETH ANN (PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:ANN
Last Name:BASTIEN
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6501 SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-9707
Mailing Address - Country:US
Mailing Address - Phone:317-423-8226
Mailing Address - Fax:
Practice Address - Street 1:6501 SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-9707
Practice Address - Country:US
Practice Address - Phone:317-423-8226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-25
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1107273103T00000X
IN966410103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN966410OtherILLINOIS AND INDIANA CERTIFICATIONS
IL1107273OtherCERTIFICATIONS