Provider Demographics
NPI:1952977431
Name:BASCOM, DOREEN ESTELLA
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:ESTELLA
Last Name:BASCOM
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:DOREEN
Other - Middle Name:E
Other - Last Name:BASCOM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RMHC
Mailing Address - Street 1:7603 LA MESITA CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-2422
Mailing Address - Country:US
Mailing Address - Phone:646-468-7255
Mailing Address - Fax:
Practice Address - Street 1:1001 E BAKER ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-3700
Practice Address - Country:US
Practice Address - Phone:813-754-5555
Practice Address - Fax:813-754-5552
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH20921101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health