Provider Demographics
NPI:1942492756
Name:BASISTA, RITA M (PTA ,)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:M
Last Name:BASISTA
Suffix:
Gender:F
Credentials:PTA ,
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 2327
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650
Mailing Address - Country:US
Mailing Address - Phone:301-997-1155
Mailing Address - Fax:
Practice Address - Street 1:40900 MERCHANT LANE
Practice Address - Street 2:BLAIR BUILDING SUITE 202
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650
Practice Address - Country:US
Practice Address - Phone:301-997-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA2221225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant