Basic Information
| Provider Information | |||||||||
| NPI: | 1447346465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASHAM | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GERSTNER | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | C. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2350 WOODMOOR LN | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530454259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627961045 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16535 W BLUEMOUND RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530055936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625423255 | ||||||||
| FaxNumber: | 2628216180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 09/24/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 468-124 | WI | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.