Provider Demographics
NPI:1629798897
Name:BASAULA, BINOD PRASAD (MS, LADC, LPCC)
Entity type:Individual
Prefix:
First Name:BINOD
Middle Name:PRASAD
Last Name:BASAULA
Suffix:
Gender:M
Credentials:MS, LADC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9257 LOWER 6TH ST N
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-4101
Mailing Address - Country:US
Mailing Address - Phone:612-308-5068
Mailing Address - Fax:
Practice Address - Street 1:2000 WHITE BEAR AVE N
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-3713
Practice Address - Country:US
Practice Address - Phone:651-437-4209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305355101YA0400X
MN3344101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty