MEDICARE: THOMAS JOHN BASOLO LAC

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	BBH-SWLC-LIC-71592	MT
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	BBH-LAC-LIC-64524	MT

General Provider Information

NPI Number	:	1861270944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS JOHN BASOLO LAC

Provider Business Mailing Address
First Line	:	3000 PALMER ST STE B
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59808-1671
Country	:	US
Telephone Number	:	406-541-4673
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 PALMER ST STE B
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59808-1671
Country	:	US
Telephone Number	:	406-541-4673
Fax Number	:

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

Provider Enumeration Date	:	09/19/2023
Last Update Date	:	01/21/2026

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