Provider Demographics
NPI:1235434200
Name:BASCHLEBEN, NICOLE LEE (LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:BASCHLEBEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 BIRCH AVE
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-1416
Mailing Address - Country:US
Mailing Address - Phone:541-942-3939
Mailing Address - Fax:
Practice Address - Street 1:37 N 6TH ST
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-2012
Practice Address - Country:US
Practice Address - Phone:541-623-6053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL113011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical