Provider Demographics
NPI:1811168172
Name:BASSO, JILL LORI (MA BCBA)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:LORI
Last Name:BASSO
Suffix:
Gender:F
Credentials:MA BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 MEDIO ST.
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501
Mailing Address - Country:US
Mailing Address - Phone:505-986-6114
Mailing Address - Fax:
Practice Address - Street 1:1705 MEDIO ST.
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501
Practice Address - Country:US
Practice Address - Phone:505-986-6114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-14
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CERT#1-03-1109 BCBA101Y00000X
NM6162225700000X
NM1-03-1109103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist