Healthcare Provider Details

I. General information

NPI: 1831646439
Provider Name (Legal Business Name): JACQUELINE MARIE BASILE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 MONUMENT RD
PHILADELPHIA PA
19131-1625
US

IV. Provider business mailing address

4200 MONUMENT RD
PHILADELPHIA PA
19131-1625
US

V. Phone/Fax

Practice location:
  • Phone: 215-581-3748
  • Fax: 215-581-3781
Mailing address:
  • Phone: 215-581-3748
  • Fax: 215-581-3781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW016836
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: