Provider Demographics
NPI:1639795347
Name:BASEL, CAROLE ANNE
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:ANNE
Last Name:BASEL
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 1:6562 WELANNEE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAUREL HILL
Mailing Address - State:FL
Mailing Address - Zip Code:32567-7311
Mailing Address - Country:US
Mailing Address - Phone:805-588-2575
Mailing Address - Fax:
Practice Address - Street 1:6562 WELANNEE BLVD
Practice Address - Street 2:
Practice Address - City:LAUREL HILL
Practice Address - State:FL
Practice Address - Zip Code:32567-7311
Practice Address - Country:US
Practice Address - Phone:805-588-2575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-18
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109181800Medicaid