Healthcare Provider Details

I. General information

NPI: 1609380344
Provider Name (Legal Business Name): TODD BASTA LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3033 N CENTRAL AVE STE 700
PHOENIX AZ
85012-2806
US

IV. Provider business mailing address

8275 E BELL RD APT 1139
SCOTTSDALE AZ
85260-1031
US

V. Phone/Fax

Practice location:
  • Phone: 602-230-7373
  • Fax: 602-257-8029
Mailing address:
  • Phone: 480-319-3533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-16952
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number16952
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: