Provider Demographics
NPI:1477055184
Name:BASNER, DIANE ERICA (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:ERICA
Last Name:BASNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 DORSET XING UNIT 535
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-1479
Mailing Address - Country:US
Mailing Address - Phone:601-608-8884
Mailing Address - Fax:
Practice Address - Street 1:55 DORSET XING UNIT 535
Practice Address - Street 2:
Practice Address - City:SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06070-1479
Practice Address - Country:US
Practice Address - Phone:601-608-8884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219541104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker