Healthcare Provider Details

I. General information

NPI: 1073145587
Provider Name (Legal Business Name): RENEA BASS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20601 N 19TH AVE STE 100
PHOENIX AZ
85027-2666
US

IV. Provider business mailing address

6416 NW 5TH WAY
FORT LAUDERDALE FL
33309-6112
US

V. Phone/Fax

Practice location:
  • Phone: 887-540-3988
  • Fax: 954-982-6491
Mailing address:
  • Phone: 888-754-0398
  • Fax: 954-982-6491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: