Basic Information
| Provider Information | |||||||||
| NPI: | 1336776293 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASLANDZE | ||||||||
| FirstName: | SOPHIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 REVERE DR | ||||||||
| Address2: | |||||||||
| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600621566 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 606 E BALTIMORE PIKE | ||||||||
| Address2: | |||||||||
| City: | MEDIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190631751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108647376 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2020 | ||||||||
| LastUpdateDate: | 03/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 11833036 | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.