Healthcare Provider Details

I. General information

NPI: 1174624589
Provider Name (Legal Business Name): ILEANA BASCUAS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 05/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 N 12TH AVE BLDG B
ARCADIA FL
34266-8752
US

IV. Provider business mailing address

PO BOX 22197
SARASOTA FL
34276-5197
US

V. Phone/Fax

Practice location:
  • Phone: 863-494-1242
  • Fax: 863-491-0466
Mailing address:
  • Phone: 941-809-4091
  • Fax: 941-845-4963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY5016
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY5016
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: