Provider Demographics
NPI:1447862115
Name:BASANTSOV, ALEVTINA
Entity type:Individual
Prefix:
First Name:ALEVTINA
Middle Name:
Last Name:BASANTSOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 NE 2ND AVE APT 3106
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33132-2920
Mailing Address - Country:US
Mailing Address - Phone:561-543-0441
Mailing Address - Fax:
Practice Address - Street 1:450 N PARK RD STE 400
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6918
Practice Address - Country:US
Practice Address - Phone:954-925-3191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-23
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-23-64699103K00000X, 103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1-23-64699OtherBOARD CERTIFIED BEHAVIOR ANALYST
101Y00000XOtherMENTAL HEALTH COUNSELOR
106S00000XOtherBEHAVIOR TECHNICIAN