Healthcare Provider Details

I. General information

NPI: 1760951792
Provider Name (Legal Business Name): ELISE HOPE BASILETTI DSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2018
Last Update Date: 11/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 N MERIDIAN ST
INDIANAPOLIS IN
46204-3021
US

IV. Provider business mailing address

60 MULBERRY CT
LAFAYETTE IN
47905-3934
US

V. Phone/Fax

Practice location:
  • Phone: 317-232-7349
  • Fax:
Mailing address:
  • Phone: 765-409-1829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: