Provider Demographics
NPI:1306412200
Name:BASCOS, KIEZEL D
Entity type:Individual
Prefix:
First Name:KIEZEL
Middle Name:D
Last Name:BASCOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W CARSON ST APT 206
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-2843
Mailing Address - Country:US
Mailing Address - Phone:310-357-9310
Mailing Address - Fax:
Practice Address - Street 1:713 W COMMONWEALTH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832
Practice Address - Country:US
Practice Address - Phone:714-879-4274
Practice Address - Fax:714-879-2274
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician