Provider Demographics
NPI:1801525951
Name:BASKERVILLE, LIZETTE SHANTA
Entity type:Individual
Prefix:
First Name:LIZETTE
Middle Name:SHANTA
Last Name:BASKERVILLE
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 1:225 SPRING HILL LN
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27537-7238
Mailing Address - Country:US
Mailing Address - Phone:252-767-6960
Mailing Address - Fax:
Practice Address - Street 1:120 E BELLE ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-4502
Practice Address - Country:US
Practice Address - Phone:252-573-2933
Practice Address - Fax:252-572-4745
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician