Provider Demographics
NPI:1750757126
Name:BASCUINE, TAVIA-SIMONE
Entity type:Individual
Prefix:
First Name:TAVIA-SIMONE
Middle Name:
Last Name:BASCUINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 MAIN STREET
Mailing Address - Street 2:#143
Mailing Address - City:EAST BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06023
Mailing Address - Country:US
Mailing Address - Phone:203-932-7330
Mailing Address - Fax:
Practice Address - Street 1:300 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516
Practice Address - Country:US
Practice Address - Phone:203-932-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTMSW.002363101YM0800X
CT58.010762101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health