Provider Demographics
NPI:1912110461
Name:BASOW, SUSAN A (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:A
Last Name:BASOW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 PAXINOSA ROAD EAST
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-1334
Mailing Address - Country:US
Mailing Address - Phone:610-258-0249
Mailing Address - Fax:610-330-5349
Practice Address - Street 1:209 PAXINOSA ROAD EAST
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18040-1334
Practice Address - Country:US
Practice Address - Phone:610-258-0249
Practice Address - Fax:610-330-5349
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS004132L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist