Provider Demographics
NPI:1396832374
Name:BASARABA, ROSE X (LAC)
Entity Type:Individual
Prefix:MS
First Name:ROSE
Middle Name:
Last Name:BASARABA
Suffix:X
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 E BISMARCK EXPY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-6500
Mailing Address - Country:US
Mailing Address - Phone:701-224-1615
Mailing Address - Fax:
Practice Address - Street 1:433 E BISMARCK EXPY
Practice Address - Street 2:SUITE 3
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-6500
Practice Address - Country:US
Practice Address - Phone:701-224-1615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDLAC 1006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)