Provider Demographics
NPI:1831183623
Name:BASCOM, PHILIP GLEN (LCSW)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:GLEN
Last Name:BASCOM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 7TH ST BLDG 700
Mailing Address - Street 2:
Mailing Address - City:ROBINS AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31098-2227
Mailing Address - Country:US
Mailing Address - Phone:850-461-2083
Mailing Address - Fax:
Practice Address - Street 1:655 7TH ST BLDG 700
Practice Address - Street 2:
Practice Address - City:ROBINS AFB
Practice Address - State:GA
Practice Address - Zip Code:31098-2227
Practice Address - Country:US
Practice Address - Phone:850-461-2083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC42451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical