Provider Demographics
NPI:1043356322
Name:BASTABLE, EOIN (LCSW)
Entity type:Individual
Prefix:MR
First Name:EOIN
Middle Name:
Last Name:BASTABLE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 NE 32ND PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-7710
Mailing Address - Country:US
Mailing Address - Phone:503-360-7011
Mailing Address - Fax:
Practice Address - Street 1:4520 NE 32ND PL
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-7710
Practice Address - Country:US
Practice Address - Phone:503-360-7011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL11451101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health