Provider Demographics
NPI:1013217546
Name:BASLOCK, DANIEL (MSW)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:BASLOCK
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 HILLTOP AVE
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-4327
Mailing Address - Country:US
Mailing Address - Phone:802-535-9114
Mailing Address - Fax:
Practice Address - Street 1:190 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-5606
Practice Address - Country:US
Practice Address - Phone:802-535-9114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT151.0126712101YA0400X
VT089.00904881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1022005Medicaid
NHRE 2534Medicare PIN