Provider Demographics
NPI:1871964007
Name:BASURTO, SHANTEL MARIE (LISW)
Entity type:Individual
Prefix:
First Name:SHANTEL
Middle Name:MARIE
Last Name:BASURTO
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:SHANTEL
Other - Middle Name:MARIE
Other - Last Name:LEARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:3316 CEDAR HEIGHTS DR STE A
Mailing Address - Street 2:
Mailing Address - City:CEDAR FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50613-6083
Mailing Address - Country:US
Mailing Address - Phone:319-504-4593
Mailing Address - Fax:319-260-1212
Practice Address - Street 1:3316 CEDAR HEIGHTS DR
Practice Address - Street 2:SUITE A
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613-6083
Practice Address - Country:US
Practice Address - Phone:319-504-4593
Practice Address - Fax:319-274-9147
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-14
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0081831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0707633Medicaid