Provider Demographics
NPI:1487701058
Name:BASCOM, TIFFANY ANN (LCPC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:BASCOM
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-1923
Mailing Address - Country:US
Mailing Address - Phone:208-233-5433
Mailing Address - Fax:208-284-2783
Practice Address - Street 1:2520 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-1923
Practice Address - Country:US
Practice Address - Phone:208-233-5433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-3801101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1684791Medicare ID - Type Unspecified