=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508324955
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GILLIAN BASEDOW ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2019
-----------------------------------------------------
Last Update Date | 01/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4433 VESTAL PKWY E FL 2
-----------------------------------------------------
City | VESTAL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13850-3556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-803-0471
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4433 VESTAL PKWY E FL 2
-----------------------------------------------------
City | VESTAL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13850-3556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-803-0471
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 004370
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------