Provider Demographics
NPI:1174624589
Name:BASCUAS, ILEANA (PHD)
Entity type:Individual
Prefix:
First Name:ILEANA
Middle Name:
Last Name:BASCUAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22197
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34276-5197
Mailing Address - Country:US
Mailing Address - Phone:941-809-4091
Mailing Address - Fax:941-845-4963
Practice Address - Street 1:725 N 12TH AVE BLDG B
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-8752
Practice Address - Country:US
Practice Address - Phone:863-494-1242
Practice Address - Fax:863-491-0466
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5016103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59604CMedicare PIN