Provider Demographics
NPI:1700179090
Name:BASCOM, LEE AMES (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:LEE
Middle Name:AMES
Last Name:BASCOM
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 N KIRKWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-2639
Mailing Address - Country:US
Mailing Address - Phone:360-628-8612
Mailing Address - Fax:
Practice Address - Street 1:1121 OLIVETTE EXECUTIVE PWKY STE 205
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-1641
Practice Address - Country:US
Practice Address - Phone:314-991-9058
Practice Address - Fax:314-993-2050
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-19
Last Update Date:2021-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040317391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical