Provider Demographics
NPI:1043256480
Name:BASAL, JOHN (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BASAL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 OLD COUNTRY RD
Mailing Address - Street 2:SUITE 271
Mailing Address - City:CARLE PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11514-1801
Mailing Address - Country:US
Mailing Address - Phone:800-725-6280
Mailing Address - Fax:800-725-6380
Practice Address - Street 1:780 ALBANY SHAKER RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12211-1055
Practice Address - Country:US
Practice Address - Phone:518-869-2231
Practice Address - Fax:518-869-1713
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY06871-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00737393Medicaid
NY00737393Medicaid