| Organization Name: | LAKESIDE THERAPY GROUP |
| NPI Number: | 1033312574 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | STACY ELIZABETH BASTIN (MEMBER SPEECH THERAPIST) |
| Mailing Address: | 765 Brightridge Drive Bridgeport |
| State: | WV US |
| Postal Code: | 26330 |
| Phone Number: | 3048440099 |
| Fax Number: | 3048480265 |
| NPI Enumeration Date: | 06/11/2007 |
| NPI Last Update Date: | 07/09/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 235Z00000X |
| License Number: | SLP 0710 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WV |
| Taxonomy Type: | Speech, Language and Hearing Service Providers |
| Taxonomy Classification: | Speech-Language Pathologist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A speech pathologist is a person qualified by a master |