Healthcare Provider Details

I. General information

NPI: 1861425035
Provider Name (Legal Business Name): KATHLEEN ANN BASILE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 WORCESTER ST SUITE 130
WELLESLEY MA
02482-3744
US

IV. Provider business mailing address

888 WORCESTER ST SUITE 130
WELLESLEY MA
02482-3744
US

V. Phone/Fax

Practice location:
  • Phone: 617-964-6681
  • Fax: 339-686-2561
Mailing address:
  • Phone: 617-964-6681
  • Fax: 339-686-2561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3573
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: