=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316323223
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KILLY BASCOM, LICSW, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2015
-----------------------------------------------------
Last Update Date | 09/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1222 PUTNEY RD
-----------------------------------------------------
City | BRATTLEBORO
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05301-9000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-662-1655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8473
-----------------------------------------------------
City | BRATTLEBORO
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05304-8473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-662-1655
-----------------------------------------------------
Fax | 802-662-1655
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KILLY BASCOM
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 802-662-1655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0890087148
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------