Provider Demographics
NPI:1568042679
Name:BASCOME, SURRAINE (LMSW)
Entity Type:Individual
Prefix:
First Name:SURRAINE
Middle Name:
Last Name:BASCOME
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 KEARNY AVE # 202
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-2604
Mailing Address - Country:US
Mailing Address - Phone:973-573-9505
Mailing Address - Fax:
Practice Address - Street 1:434 KEARNY AVE
Practice Address - Street 2:
Practice Address - City:KEARNY
Practice Address - State:NJ
Practice Address - Zip Code:07032-2604
Practice Address - Country:US
Practice Address - Phone:646-741-4662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY110011104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker