1669427845 NPI number — MRS. MACHELLE OUTLAW BASS LPC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669427845 NPI number — MRS. MACHELLE OUTLAW BASS LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASS
Provider First Name:
MACHELLE
Provider Middle Name:
OUTLAW
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OUTLAW
Provider Other First Name:
HOPE
Provider Other Middle Name:
MACHELLE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1669427845
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
191 FIVE POINTS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUDLEY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28333-5261
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-581-8198
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 N BREAZEALE AVE UNIT C
Provider Second Line Business Practice Location Address:
UNIT E
Provider Business Practice Location Address City Name:
MOUNT OLIVE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28365-1106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-658-7500
Provider Business Practice Location Address Fax Number:
919-658-7509
Provider Enumeration Date:
05/24/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  3563 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)