Provider Demographics
NPI:1013433937
Name:BASCO, TESSA CLAIRE (LISW)
Entity Type:Individual
Prefix:MRS
First Name:TESSA
Middle Name:CLAIRE
Last Name:BASCO
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:MS
Other - First Name:TESSA
Other - Middle Name:CLAIRE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 426
Mailing Address - Street 2:
Mailing Address - City:LAKE PROVIDENCE
Mailing Address - State:LA
Mailing Address - Zip Code:71254-0426
Mailing Address - Country:US
Mailing Address - Phone:318-559-2248
Mailing Address - Fax:318-559-3381
Practice Address - Street 1:SUMMA FAMILY MEDICINE CENTER
Practice Address - Street 2:55 ARCH ST SUITE 3A
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304
Practice Address - Country:US
Practice Address - Phone:330-375-3584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.17005131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0247305Medicaid