Provider Demographics
NPI:1366687006
Name:BASCOM, KILLY J (LICSW)
Entity Type:Individual
Prefix:
First Name:KILLY
Middle Name:J
Last Name:BASCOM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 PARK PL
Mailing Address - Street 2:STE 101
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-2802
Mailing Address - Country:US
Mailing Address - Phone:802-246-1221
Mailing Address - Fax:802-246-1002
Practice Address - Street 1:36 PARK PL
Practice Address - Street 2:STE 101
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-2802
Practice Address - Country:US
Practice Address - Phone:802-246-1221
Practice Address - Fax:802-246-1002
Is Sole Proprietor?:No
Enumeration Date:2008-12-10
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.00871481041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical