Healthcare Provider Details

I. General information

NPI: 1043172703
Provider Name (Legal Business Name): ODESSA BASCOM LMSW
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 BEACH 19TH ST
FAR ROCKAWAY NY
11691-4423
US

IV. Provider business mailing address

327 BEACH 19TH ST
FAR ROCKAWAY NY
11691-4423
US

V. Phone/Fax

Practice location:
  • Phone: 718-869-7000
  • Fax:
Mailing address:
  • Phone: 718-869-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number126711
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: