Provider Demographics
NPI:1922438027
Name:BASILE, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BASILE
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 1:1326 S LATAH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2999
Mailing Address - Country:US
Mailing Address - Phone:325-762-0925
Mailing Address - Fax:
Practice Address - Street 1:9518 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8103
Practice Address - Country:US
Practice Address - Phone:208-376-4571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-26
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG1678225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist