Provider Demographics
NPI:1710575188
Name:BASEN, ALICIA (RD,LD)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:BASEN
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3849 SILSBY CT
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011-3476
Mailing Address - Country:US
Mailing Address - Phone:419-722-5016
Mailing Address - Fax:
Practice Address - Street 1:3849 SILSBY CT
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-3476
Practice Address - Country:US
Practice Address - Phone:419-722-5016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-01
Last Update Date:2021-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6959133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered