Organization
LAKESIDE THERAPY GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. STACY ELIZABETH BASTIN MA CCC SLP (MEMBER SPEECH THERAPIST)
(304) 844-0099
Entity
Organization
Contact information
Practice address
765 BRIGHTRIDGE DRIVE, BRIDGEPORT, WV 26330
(304) 844-0099
(304) 848-0265
Mailing address
765 BRIGHTRIDGE DRIVE, BRIDGEPORT, WV 26330
(304) 844-0099
(304) 848-0265
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
SLP 0710
WV
Other
Enumeration date
06/11/2007
Last updated
08/22/2020
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