Provider Demographics
NPI:1215407895
Name:BASEDOW, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:BASEDOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 GATES AVE
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803
Mailing Address - Country:US
Mailing Address - Phone:516-512-3770
Mailing Address - Fax:
Practice Address - Street 1:151 BURRS LANE
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746
Practice Address - Country:US
Practice Address - Phone:631-643-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101965104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty