Provider Demographics
NPI:1821305194
Name:BASCOM, KIMBERLY T (PTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:T
Last Name:BASCOM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 FACTORY ST
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12832-1312
Mailing Address - Country:US
Mailing Address - Phone:518-361-9753
Mailing Address - Fax:
Practice Address - Street 1:429 AVIATION RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-2914
Practice Address - Country:US
Practice Address - Phone:518-824-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005165225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant