1619320918 NPI number — SAMUEL SCOTT BASS MS, MDIV, LMFT

Table of content: SAMUEL SCOTT BASS MS, MDIV, LMFT (NPI 1619320918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619320918 NPI number — SAMUEL SCOTT BASS MS, MDIV, LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASS
Provider First Name:
SAMUEL
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, MDIV, LMFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BASS
Provider Other First Name:
SCOTT
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, MDIV, LMFT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1619320918
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25032
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27611-5032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-760-5430
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4601 LAKE BOONE TRL
Provider Second Line Business Practice Location Address:
SUITE 3B
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27607-7503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-760-5430
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/21/2016

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: 106H00000X , with the licence number:  LMFT 1702 , 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)





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