MEDICARE: GILBERTE BASTIEN PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY004074	GA

General Provider Information

NPI Number	:	1225522477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GILBERTE BASTIEN PHD

Provider Business Mailing Address
First Line	:	4928 LONGVIEW RUN
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30035-4096
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5975 PARKWAY NORTH BLVD STE D
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30040-8255
Country	:	US
Telephone Number	:	404-388-3909
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2018
Last Update Date	:	06/20/2018

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Directions to “ GILBERTE BASTIEN PHD” Practice Location

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