Healthcare Provider Details

I. General information

NPI: 1346498664
Provider Name (Legal Business Name): JASON R BASSILAKIS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4024 CENTRAL AVE
ST PETERSBURG FL
33711-1239
US

IV. Provider business mailing address

PO BOX 10970 THE COUNSELING CENTER
ST PETERSBURG FL
33733-0970
US

V. Phone/Fax

Practice location:
  • Phone: 727-327-7656
  • Fax: 727-322-2110
Mailing address:
  • Phone: 727-327-7656
  • Fax: 727-322-2110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW12979
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number116380
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: