Provider Demographics
NPI:1811762651
Name:BASCOM, BERNADETTE
Entity type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:BASCOM
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:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98041-0268
Mailing Address - Country:US
Mailing Address - Phone:206-755-6091
Mailing Address - Fax:
Practice Address - Street 1:9622 NE 195TH CIR APT H1
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-2978
Practice Address - Country:US
Practice Address - Phone:206-755-6091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1912-68670385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care