Provider Demographics
NPI:1043853948
Name:BASCOM, ELISE NOEL (PHD)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:NOEL
Last Name:BASCOM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4010
Mailing Address - Country:US
Mailing Address - Phone:541-517-9733
Mailing Address - Fax:
Practice Address - Street 1:1551 PEARL ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4010
Practice Address - Country:US
Practice Address - Phone:541-517-9733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3154103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist