Provider Demographics
NPI:1902914476
Name:BASISTA, MARYANN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:BASISTA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 BUTTERFIELD RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-5602
Mailing Address - Country:US
Mailing Address - Phone:630-788-8040
Mailing Address - Fax:630-424-0425
Practice Address - Street 1:1315 BUTTERFIELD RD
Practice Address - Street 2:SUITE 220
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5602
Practice Address - Country:US
Practice Address - Phone:630-788-8040
Practice Address - Fax:630-424-0425
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2013-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149 006503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD813202000OtherMAGELLAN
IL2167954OtherCOMPSYCH
CT7851779OtherAETNA
IL9426416OtherPHCS
TX183695OtherVALUE OPTIONS
IL11713175OtherCAQH
TX506974809OtherUBH
IL2221790OtherBCBS
MN2567375OtherCIGNA