Provider Demographics
NPI:1851865570
Name:MASEVERIYO, IRENE BASIL
Entity Type:Individual
Prefix:
First Name:IRENE BASIL
Middle Name:
Last Name:MASEVERIYO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 W BURGESS LN
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-1919
Mailing Address - Country:US
Mailing Address - Phone:331-803-0822
Mailing Address - Fax:
Practice Address - Street 1:4505 W BURGESS LN
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-1919
Practice Address - Country:US
Practice Address - Phone:331-803-0822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5585106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty