Provider Demographics
NPI:1295083434
Name:BASILE, KELLEY S
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:S
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 1:20920 42ND AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2750
Mailing Address - Country:US
Mailing Address - Phone:718-423-0247
Mailing Address - Fax:
Practice Address - Street 1:20920 42ND AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2750
Practice Address - Country:US
Practice Address - Phone:718-423-0247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-20
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst