Provider Demographics
NPI:1881159879
Name:BASILE, SAMANTHA ANN
Entity type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:ANN
Last Name:BASILE
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 1:100 SHIELDS AVE
Mailing Address - Street 2:
Mailing Address - City:WILLISTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11596-2316
Mailing Address - Country:US
Mailing Address - Phone:516-236-9018
Mailing Address - Fax:
Practice Address - Street 1:100 SHIELDS AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-2316
Practice Address - Country:US
Practice Address - Phone:516-236-9018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency