Provider Demographics
NPI:1093437402
Name:BASCUS, SIENNA MADISON
Entity Type:Individual
Prefix:
First Name:SIENNA
Middle Name:MADISON
Last Name:BASCUS
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 1:7363 NW 34TH ST
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33319-4962
Mailing Address - Country:US
Mailing Address - Phone:954-336-2023
Mailing Address - Fax:
Practice Address - Street 1:3720 COCONUT CREEK PKWY
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33066-1634
Practice Address - Country:US
Practice Address - Phone:954-801-6327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-226962106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician