Provider Demographics
NPI:1699901777
Name:BAUCOM, BENITA GALE (LCSW-BACS)
Entity type:Individual
Prefix:MS
First Name:BENITA
Middle Name:GALE
Last Name:BAUCOM
Suffix:
Gender:F
Credentials:LCSW-BACS
Other - Prefix:MS
Other - First Name:NITA
Other - Middle Name:GALE
Other - Last Name:BAUCOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW-BACS
Mailing Address - Street 1:803 BURGUNDY ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70116-3061
Mailing Address - Country:US
Mailing Address - Phone:504-931-8784
Mailing Address - Fax:504-407-3005
Practice Address - Street 1:3005 METAIRIE ROAD
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-5215
Practice Address - Country:US
Practice Address - Phone:504-931-8784
Practice Address - Fax:504-407-3005
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-03
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3296104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker