Provider Demographics
NPI:1326552407
Name:BASILE, TARA PETERS
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:PETERS
Last Name:BASILE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:CHRISTINE
Other - Last Name:BASILE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 DODGE AVE
Mailing Address - Street 2:
Mailing Address - City:EAST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06512-3337
Mailing Address - Country:US
Mailing Address - Phone:203-988-2765
Mailing Address - Fax:
Practice Address - Street 1:91 NORTHWEST DR
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-1534
Practice Address - Country:US
Practice Address - Phone:203-988-2765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor