Provider Demographics
NPI:1740087055
Name:BASULTO, YASSIEL
Entity type:Individual
Prefix:MRS
First Name:YASSIEL
Middle Name:
Last Name:BASULTO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 RIDGEMONT DR
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL JUNCTION
Mailing Address - State:NY
Mailing Address - Zip Code:12533-8230
Mailing Address - Country:US
Mailing Address - Phone:718-749-7108
Mailing Address - Fax:
Practice Address - Street 1:136 RIDGEMONT DR
Practice Address - Street 2:
Practice Address - City:HOPEWELL JUNCTION
Practice Address - State:NY
Practice Address - Zip Code:12533-8230
Practice Address - Country:US
Practice Address - Phone:718-749-7108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool