Provider Demographics
NPI:1184664351
Name:BASABE, ANGEL RAFAEL (LICENSED CLINICAL SO)
Entity Type:Individual
Prefix:MR
First Name:ANGEL
Middle Name:RAFAEL
Last Name:BASABE
Suffix:
Gender:M
Credentials:LICENSED CLINICAL SO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 320683
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-6111
Mailing Address - Country:US
Mailing Address - Phone:414-677-0155
Mailing Address - Fax:414-677-0153
Practice Address - Street 1:313 N PLANKINTON AVE STE 207
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53203-3104
Practice Address - Country:US
Practice Address - Phone:414-677-0155
Practice Address - Fax:414-677-0153
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23231231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39539200Medicaid
501530Medicare UPIN