Provider Demographics
NPI:1356920995
Name:BASIL, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BASIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 GIRARD BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-1718
Mailing Address - Country:US
Mailing Address - Phone:505-318-0253
Mailing Address - Fax:
Practice Address - Street 1:1721 GIRARD BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-1718
Practice Address - Country:US
Practice Address - Phone:505-318-0253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-02
Last Update Date:2023-04-12
Deactivation Date:2023-04-01
Deactivation Code:
Reactivation Date:2023-04-12
Provider Licenses
StateLicense IDTaxonomies
NMCMH0224311101YM0800X
NMT-CTL0220811101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health