Provider Demographics
NPI:1265948087
Name:BASULTO, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BASULTO
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 1:9771 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5560
Mailing Address - Country:US
Mailing Address - Phone:951-552-7522
Mailing Address - Fax:
Practice Address - Street 1:9771 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5560
Practice Address - Country:US
Practice Address - Phone:951-552-7522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2025-05-16
Deactivation Date:2021-03-01
Deactivation Code:
Reactivation Date:2021-03-19
Provider Licenses
StateLicense IDTaxonomies
CALMFT155125106H00000X
CAAMFT124251101YM0800X, 106H00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst