Provider Demographics
NPI:1326161811
Name:BASA, GUS ANTHONY (PT)
Entity Type:Individual
Prefix:
First Name:GUS
Middle Name:ANTHONY
Last Name:BASA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:GUS ANTHONY
Other - Middle Name:VILLALUZ
Other - Last Name:BASA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:5214 S EAST STREET
Mailing Address - Street 2:BUILDING D SUITE 1
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227
Mailing Address - Country:US
Mailing Address - Phone:800-486-4449
Mailing Address - Fax:317-780-3750
Practice Address - Street 1:5214 S EAST STREET
Practice Address - Street 2:BUILDING D SUITE 1 HTS OUTPATIENT THERAPY SERVICES
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227
Practice Address - Country:US
Practice Address - Phone:800-486-4449
Practice Address - Fax:317-780-3750
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007968A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist