Provider Demographics
NPI:1639586407
Name:BASA, MELITTA
Entity Type:Individual
Prefix:
First Name:MELITTA
Middle Name:
Last Name:BASA
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 1:3111 N HOUSTON ST APT 1110
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-7865
Mailing Address - Country:US
Mailing Address - Phone:607-237-1414
Mailing Address - Fax:
Practice Address - Street 1:433 VIA DEL ORSO DR
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33477-4212
Practice Address - Country:US
Practice Address - Phone:607-237-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health