Provider Demographics
NPI:1447378443
Name:BASILE, BRENT ANTONY (LISW)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:ANTONY
Last Name:BASILE
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1629 ONONDAGA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4310
Mailing Address - Country:US
Mailing Address - Phone:216-374-8382
Mailing Address - Fax:
Practice Address - Street 1:1629 ONONDAGA AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4310
Practice Address - Country:US
Practice Address - Phone:216-374-8382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.07000261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical