Provider Demographics
NPI:1790061497
Name:BASILE, ELIZABETH CONCORDIA (MA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CONCORDIA
Last Name:BASILE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SAN ANTONIO CIR
Mailing Address - Street 2:SUITE C-125
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-1254
Mailing Address - Country:US
Mailing Address - Phone:408-718-6915
Mailing Address - Fax:
Practice Address - Street 1:201 SAN ANTONIO CIR
Practice Address - Street 2:SUITE C-125
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-1254
Practice Address - Country:US
Practice Address - Phone:408-718-6915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC48300106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist