Provider Demographics
NPI:1467189993
Name:BASILICI, ANJA
Entity Type:Individual
Prefix:
First Name:ANJA
Middle Name:
Last Name:BASILICI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5948 FISHER RD STE 202
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-5751
Mailing Address - Country:US
Mailing Address - Phone:191-058-4199
Mailing Address - Fax:910-766-6080
Practice Address - Street 1:5948 FISHER RD STE 202
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-5751
Practice Address - Country:US
Practice Address - Phone:191-058-4199
Practice Address - Fax:910-766-6080
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
22228092106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician