Provider Demographics
NPI:1851788798
Name:BASHA, TIMOTHY W (LADAC)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:W
Last Name:BASHA
Suffix:
Gender:M
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1088
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88311-1088
Mailing Address - Country:US
Mailing Address - Phone:575-495-8098
Mailing Address - Fax:866-521-8354
Practice Address - Street 1:1613 JUNIPER DR.
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310
Practice Address - Country:US
Practice Address - Phone:575-495-8098
Practice Address - Fax:866-521-8354
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-17
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0147651101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)