Provider Demographics
NPI:1770071623
Name:BASILETTI, MICHELE R (LPCC-LICDC)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:R
Last Name:BASILETTI
Suffix:
Gender:F
Credentials:LPCC-LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28000 MAYS SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:TIPPECANOE
Mailing Address - State:OH
Mailing Address - Zip Code:44699-9449
Mailing Address - Country:US
Mailing Address - Phone:330-440-8882
Mailing Address - Fax:
Practice Address - Street 1:130 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-2934
Practice Address - Country:US
Practice Address - Phone:330-343-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2001821101YP2500X, 101YP2500X
OHLICDC.161823101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty