Provider Demographics
NPI:1255744827
Name:ASCENCIO, ALICIA (LCSW)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:ASCENCIO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:
Other - Last Name:KEITHLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:112 12TH AVE RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5011
Mailing Address - Country:US
Mailing Address - Phone:208-630-3780
Mailing Address - Fax:
Practice Address - Street 1:112 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5011
Practice Address - Country:US
Practice Address - Phone:208-465-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-364231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical