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General NPI Number Information
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NPI Number | 1760975205
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Entity Type | Individual
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Provider Name | SONIA BASTA
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Gender | Female
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Dates
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Enumeration Date | 06/10/2018
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Last Update Date | 06/10/2018
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Provider Practice Location Address
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Address Line | 23101 STADIUM DR
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City | SAINT CLAIR SHORES
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State | MI
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Zip | 48080-3208
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Country | US
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Telephone | 586-435-1600
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Fax |
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Provider Business Mailing Address
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Address Line | 5128 CRESTMONT DR
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City | TROY
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State | MI
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Zip | 48098-5309
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Country | US
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Telephone | 248-703-2236
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 7101005029
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License Number State | MI
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