MEDICARE: EMMA M BASSO LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW3662	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z6316	OTHER	FL	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1740278639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMA M BASSO LCSW

Provider Business Mailing Address
First Line	:	PO BOX 6227
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32314-6227
Country	:	US
Telephone Number	:	850-386-1560
Fax Number	:	850-386-4583

Provider Business Practice Location Address
First Line	:	211B DELTA CT
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32303-4835
Country	:	US
Telephone Number	:	850-386-1560
Fax Number	:	850-386-4583

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	07/08/2007

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