Provider Demographics
NPI:1922354653
Name:DIBASIO, DARCIE ANN
Entity Type:Individual
Prefix:MS
First Name:DARCIE
Middle Name:ANN
Last Name:DIBASIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18198 MILLAR RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-2088
Mailing Address - Country:US
Mailing Address - Phone:586-465-1482
Mailing Address - Fax:
Practice Address - Street 1:5600 W MAPLE RD STE B204
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3707
Practice Address - Country:US
Practice Address - Phone:586-465-1482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704249095363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health