Provider Demographics
NPI:1992802961
Name:BASQUILL, MARK (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BASQUILL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5041 NEW CENTRE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-1680
Mailing Address - Country:US
Mailing Address - Phone:910-313-3232
Mailing Address - Fax:
Practice Address - Street 1:5041 NEW CENTRE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-1680
Practice Address - Country:US
Practice Address - Phone:910-313-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2208103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist