Provider Demographics
NPI:1588937767
Name:BASALAY, ERIN KRISTINA (PSYD)
Entity type:Individual
Prefix:DR
First Name:ERIN
Middle Name:KRISTINA
Last Name:BASALAY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MS
Other - First Name:ERIN
Other - Middle Name:
Other - Last Name:POWERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1723 S 5TH PL
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-4324
Mailing Address - Country:US
Mailing Address - Phone:847-529-6421
Mailing Address - Fax:
Practice Address - Street 1:5730 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-1580
Practice Address - Country:US
Practice Address - Phone:773-921-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008280103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical