MEDICARE: ODESSA BASCOM LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	126711	NY

General Provider Information

NPI Number	:	1043172703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ODESSA BASCOM LMSW

Provider Business Mailing Address
First Line	:	327 BEACH 19TH ST
Second Line	:
City	:	FAR ROCKAWAY
State	:	NY
Zip	:	11691-4423
Country	:	US
Telephone Number	:	718-869-7000
Fax Number	:

Provider Business Practice Location Address
First Line	:	327 BEACH 19TH ST
Second Line	:
City	:	FAR ROCKAWAY
State	:	NY
Zip	:	11691-4423
Country	:	US
Telephone Number	:	718-869-7000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2025
Last Update Date	:	12/01/2025

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