Provider Demographics
NPI:1821123233
Name:BASEY, GINA WERTALIK (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:WERTALIK
Last Name:BASEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5908 CROSS COUNTRY BLVD
Mailing Address - Street 2:APT. B
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-3841
Mailing Address - Country:US
Mailing Address - Phone:410-466-1145
Mailing Address - Fax:
Practice Address - Street 1:2360 W JOPPA RD
Practice Address - Street 2:SUITE 318
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4624
Practice Address - Country:US
Practice Address - Phone:410-825-3646
Practice Address - Fax:410-825-3649
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04201103TC0700X, 103TC2200X, 103TM1800X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist