Provider Demographics
NPI:1861048159
Name:BASCOM, KENNETH VINCENT JR (MA)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:VINCENT
Last Name:BASCOM
Suffix:JR
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 WARNER RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:NY
Mailing Address - Zip Code:12766-5045
Mailing Address - Country:US
Mailing Address - Phone:845-482-5080
Mailing Address - Fax:
Practice Address - Street 1:1855 FAIR AVE
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-2121
Practice Address - Country:US
Practice Address - Phone:570-253-3980
Practice Address - Fax:570-253-3982
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA647010101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)