=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518295468
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JULIE M BASULTO M.S., LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2009
-----------------------------------------------------
Last Update Date | 12/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18441 NW 2ND AVE SUITE 500
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33169-4517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-249-0521
-----------------------------------------------------
Fax | 305-249-0523
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18441 NW 2ND AVE SUITE 500
-----------------------------------------------------
City | MIAMI GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33169-4517
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-249-0521
-----------------------------------------------------
Fax | 305-249-0523
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MT 2348
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------