Healthcare Provider Details

I. General information

NPI: 1568883635
Provider Name (Legal Business Name): CHRISTINA BASTIAN MA, LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2013
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 E 300 N UNIT 112
VINEYARD UT
84059-2670
US

IV. Provider business mailing address

534 E 300 N UNIT 112
VINEYARD UT
84059-2670
US

V. Phone/Fax

Practice location:
  • Phone: 801-995-1789
  • Fax:
Mailing address:
  • Phone: 801-995-1789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: