Provider Demographics
NPI:1447499918
Name:BASTA, CHERYL A (LCPC 57404; LAC 1290)
Entity type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:A
Last Name:BASTA
Suffix:
Gender:F
Credentials:LCPC 57404; LAC 1290
Other - Prefix:
Other - First Name:CHERYL
Other - Middle Name:A
Other - Last Name:ROCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:PO BOX 6025
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59406-6025
Mailing Address - Country:US
Mailing Address - Phone:406-836-2714
Mailing Address - Fax:888-624-2676
Practice Address - Street 1:1301 12TH AVE S STE 103
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4600
Practice Address - Country:US
Practice Address - Phone:406-836-2714
Practice Address - Fax:888-624-2676
Is Sole Proprietor?:No
Enumeration Date:2009-02-06
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT57404101Y00000X, 101YP2500X
MT1290101YA0400X
57404101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)