Basic Information
| Provider Information | |||||||||
| NPI: | 1265948087 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASULTO | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15095 AMARGOSA RD | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923941879 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 15095 AMARGOSA RD | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923941879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602454695 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2017 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/01/2021 | ||||||||
| NPIReactivationDate: | 03/19/2021 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | AMFT124251 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.