Provider Demographics
NPI:1932231420
Name:BASIL, JILL MARIE (MOT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:BASIL
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:MARIE
Other - Last Name:REIDELBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT
Mailing Address - Street 1:9034 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2905
Mailing Address - Country:US
Mailing Address - Phone:219-836-0296
Mailing Address - Fax:219-836-0570
Practice Address - Street 1:9050 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2905
Practice Address - Country:US
Practice Address - Phone:219-836-0193
Practice Address - Fax:219-836-0570
Is Sole Proprietor?:No
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003833A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000484843OtherANTHEM
IN386960JMedicare ID - Type UnspecifiedMEDICARE