Provider Demographics
NPI:1205644358
Name:BASILISCO, ANJULI NAMEER
Entity type:Individual
Prefix:
First Name:ANJULI
Middle Name:NAMEER
Last Name:BASILISCO
Suffix:
Gender:U
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49651 GOLDEN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-3549
Mailing Address - Country:US
Mailing Address - Phone:586-536-5120
Mailing Address - Fax:
Practice Address - Street 1:15023 21 MILE RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-5024
Practice Address - Country:US
Practice Address - Phone:586-286-9644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician