Provider Demographics
NPI:1487901609
Name:BASOV, ANNA R (PSYD, LCPC)
Entity type:Individual
Prefix:DR
First Name:ANNA
Middle Name:R
Last Name:BASOV
Suffix:
Gender:F
Credentials:PSYD, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 SKOKIE BOULEVARD
Mailing Address - Street 2:SUITE #LL-5D
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60060-2813
Mailing Address - Country:US
Mailing Address - Phone:847-607-1589
Mailing Address - Fax:847-881-0839
Practice Address - Street 1:601 SKOKIE BLVD
Practice Address - Street 2:SUITE #LL-5D
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2851
Practice Address - Country:US
Practice Address - Phone:847-607-1589
Practice Address - Fax:847-881-0839
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009063101YP2500X
IL178.007955101YP2500X
IL071009153103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional