Provider Demographics
NPI:1982918579
Name:BASALO, DENNIS (OTR/L)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:BASALO
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 HAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-8235
Mailing Address - Country:US
Mailing Address - Phone:415-218-6644
Mailing Address - Fax:
Practice Address - Street 1:811 COURT ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2131
Practice Address - Country:US
Practice Address - Phone:415-218-6644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2681225X00000X
TX110586225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist