Provider Demographics
NPI:1346498664
Name:BASSILAKIS, JASON R (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:R
Last Name:BASSILAKIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10970
Mailing Address - Street 2:THE COUNSELING CENTER
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733-0970
Mailing Address - Country:US
Mailing Address - Phone:727-327-7656
Mailing Address - Fax:727-322-2110
Practice Address - Street 1:4024 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-1239
Practice Address - Country:US
Practice Address - Phone:727-327-7656
Practice Address - Fax:727-322-2110
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW129791041C0700X
MA1163801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015735800Medicaid
FLII077ZMedicare PIN