Provider Demographics
NPI:1134683006
Name:BASK PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:BASK PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:843-621-0263
Mailing Address - Street 1:1516 S LANGLEY DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-6149
Mailing Address - Country:US
Mailing Address - Phone:843-621-0263
Mailing Address - Fax:843-536-8522
Practice Address - Street 1:1516 S LANGLEY DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-6149
Practice Address - Country:US
Practice Address - Phone:843-621-0263
Practice Address - Fax:843-536-8522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-24
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS5060Medicaid