Basic Information
| Provider Information | |||||||||
| NPI: | 1174624589 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASCUAS | ||||||||
| FirstName: | ILEANA | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22197 | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342765197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9418094091 | ||||||||
| FaxNumber: | 9418454963 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 N 12TH AVE BLDG B | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342668752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634941242 | ||||||||
| FaxNumber: | 8634910466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 05/14/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PY5016 | FL | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | PY5016 | FL | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.