Provider Demographics
NPI:1518996370
Name:BASOM, JOSEPHINE
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:
Last Name:BASOM
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 1:118 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1677
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2015 TECHNOLOGY PKWY
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-9497
Practice Address - Country:US
Practice Address - Phone:717-791-2480
Practice Address - Fax:717-791-2484
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT002182E225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00149170660001Medicaid