Healthcare Provider Details

I. General information

NPI: 1356920995
Provider Name (Legal Business Name): MICHAEL BASIL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date: 04/01/2023
Reactivation Date: 04/12/2023

III. Provider practice location address

1721 GIRARD BLVD NE
ALBUQUERQUE NM
87106-1718
US

IV. Provider business mailing address

1721 GIRARD BLVD NE
ALBUQUERQUE NM
87106-1718
US

V. Phone/Fax

Practice location:
  • Phone: 505-318-0253
  • Fax:
Mailing address:
  • Phone: 505-318-0253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMH0224311
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: