Provider Demographics
NPI:1861270944
Name:BASOLO, THOMAS JOHN (LAC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:BASOLO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 S RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6621
Mailing Address - Country:US
Mailing Address - Phone:406-830-4167
Mailing Address - Fax:406-542-6632
Practice Address - Street 1:2001 S RUSSELL ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6621
Practice Address - Country:US
Practice Address - Phone:406-830-4167
Practice Address - Fax:406-542-6632
Is Sole Proprietor?:No
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-64524101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)