Healthcare Provider Details

I. General information

NPI: 1790526846
Provider Name (Legal Business Name): ALICE BLAIR BASS MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MACY DR
ROSWELL GA
30076-6335
US

IV. Provider business mailing address

1001 MACY DR
ROSWELL GA
30076-6335
US

V. Phone/Fax

Practice location:
  • Phone: 678-965-0993
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License NumberMUT000329
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: