MEDICARE: MOLLIE BASS LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	166001498	IL

General Provider Information

NPI Number	:	1669015988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLIE BASS LMFT

Provider Business Mailing Address
First Line	:	915 N RACINE AVE APT 2SE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60642-0008
Country	:	US
Telephone Number	:	206-999-0482
Fax Number	:

Provider Business Practice Location Address
First Line	:	915 N RACINE AVE APT 2SE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60642-0008
Country	:	US
Telephone Number	:	206-999-0482
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2019
Last Update Date	:	04/12/2023

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