Provider Demographics
NPI:1538953765
Name:BASTIN, LEA (LAAC)
Entity type:Individual
Prefix:MRS
First Name:LEA
Middle Name:
Last Name:BASTIN
Suffix:
Gender:F
Credentials:LAAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27215 N 230TH AVE
Mailing Address - Street 2:
Mailing Address - City:WITTMANN
Mailing Address - State:AZ
Mailing Address - Zip Code:85361-5811
Mailing Address - Country:US
Mailing Address - Phone:602-799-5985
Mailing Address - Fax:
Practice Address - Street 1:36075 S RINCON RD
Practice Address - Street 2:
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-2491
Practice Address - Country:US
Practice Address - Phone:928-418-2072
Practice Address - Fax:928-684-9592
Is Sole Proprietor?:No
Enumeration Date:2025-04-04
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAAC-15394101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor