Provider Demographics
NPI:1255542320
Name:BASILE, ANTOINETTE L (MSED)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:L
Last Name:BASILE
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:ANTOINETTE
Other - Middle Name:L
Other - Last Name:DOMITROVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED
Mailing Address - Street 1:21 WEST OMAHA STREET
Mailing Address - Street 2:
Mailing Address - City:WASHBURN
Mailing Address - State:WI
Mailing Address - Zip Code:54891-0036
Mailing Address - Country:US
Mailing Address - Phone:715-373-0160
Mailing Address - Fax:715-373-0162
Practice Address - Street 1:21 WEST OMAHA STREET
Practice Address - Street 2:
Practice Address - City:WASHBURN
Practice Address - State:WI
Practice Address - Zip Code:54891-0036
Practice Address - Country:US
Practice Address - Phone:715-373-0160
Practice Address - Fax:715-373-0162
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43592400Medicaid