Provider Demographics
NPI:1083261077
Name:BASSOLINO, DEIDRE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DEIDRE
Middle Name:
Last Name:BASSOLINO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10005-2886
Mailing Address - Country:US
Mailing Address - Phone:347-463-6807
Mailing Address - Fax:
Practice Address - Street 1:760 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5317
Practice Address - Country:US
Practice Address - Phone:718-963-5832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-23
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY025399103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program