=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114733763
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CELIA MEDNICK BASKETTE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2024
-----------------------------------------------------
Last Update Date | 12/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1021 EDEN WAY N STE 109
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-2776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-785-5540
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 604 CRESCENTWOOD ARCH
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-3580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-675-5971
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0704017579
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------