Provider Demographics
NPI:1093062754
Name:BAZINA, BASILE (MED)
Entity Type:Individual
Prefix:MR
First Name:BASILE
Middle Name:
Last Name:BAZINA
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2072
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02305-2072
Mailing Address - Country:US
Mailing Address - Phone:774-826-7416
Mailing Address - Fax:
Practice Address - Street 1:142 CRESCENT ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3104
Practice Address - Country:US
Practice Address - Phone:508-941-0005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-12
Last Update Date:2012-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health