1790766152 NPI number — MS. CAROL LOIS BASEN LCSW

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	BASEN
Provider First Name	:	CAROL
Provider Middle Name	:	LOIS
Provider Name Prefix Text	:	MS.
Provider Name Suffix Text	:
Provider Credential Text	:	LCSW
Provider Gender Code	:	F

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Provider Other Last Name	:
Provider Other First Name	:
Provider Other Middle Name	:
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Provider Other Name Suffix Text	:
Provider Other Credential Text	:
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NPI Number	:	1790766152
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	09/30/2010
NPI Deactivation Reason Code	:
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Provider First Line Business Mailing Address	:	PO BOX 2022
Provider Second Line Business Mailing Address	:
Provider Business Mailing Address City Name	:	WATERVILLE
Provider Business Mailing Address State Name	:	ME
Provider Business Mailing Address Postal Code	:	049032022
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	2073145703
Provider Business Mailing Address Fax Number	:	2078734931

Provider First Line Business Practice Location Address	:	67 SILVER ST
Provider Second Line Business Practice Location Address	:
Provider Business Practice Location Address City Name	:	WATERVILLE
Provider Business Practice Location Address State Name	:	ME
Provider Business Practice Location Address Postal Code	:	049016525
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	2073145703
Provider Business Practice Location Address Fax Number	:	2078734931
Provider Enumeration Date	:	11/10/2005

Authorized Official Last Name	:
Authorized Official First Name	:
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• Taxonomy code: 1041C0700X , with the licence number:  LC9439 , registered in the state of ME .

• Identifier: ME1790 , issued by the state of ( ME ) . This identifiers is of the category "".
• Identifier: 099016 . This is a "ANTHEM BCBS" identifier , issued by the state of ( ME ) . This identifiers is of the category "".