Provider Demographics
NPI:1124404041
Name:BASARA, STACY (LAC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BASARA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 HIGHWAY 33
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08690-1740
Mailing Address - Country:US
Mailing Address - Phone:609-588-9989
Mailing Address - Fax:
Practice Address - Street 1:2135 HIGHWAY 33
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08690-1740
Practice Address - Country:US
Practice Address - Phone:609-588-9989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00159500101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor