Basic Information
| Provider Information | |||||||||
| NPI: | 1376096255 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASULTO | ||||||||
| FirstName: | ALYSSA | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4028 1/2 WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | CUDAHY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902014181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108014134 | ||||||||
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| Practice Location | |||||||||
| Address1: | 150 N SANTA ANITA AVE STE 800 | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910063129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4242842440 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2016 | ||||||||
| LastUpdateDate: | 02/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | AMFT104086 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | LMFT104086 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.