Provider Demographics
NPI:1932529518
Name:BASILLA, CHRISTOPHER GINNO LOPEZ (PT)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER GINNO
Middle Name:LOPEZ
Last Name:BASILLA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14014 MARSH PIKE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-1638
Mailing Address - Country:US
Mailing Address - Phone:301-733-8700
Mailing Address - Fax:
Practice Address - Street 1:14014 MARSH PIKE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-1638
Practice Address - Country:US
Practice Address - Phone:301-733-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24746225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist