Healthcare Provider Details

I. General information

NPI: 1306151949
Provider Name (Legal Business Name): MRS. NANCY L BASS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 ORANGE ST
ANNA IL
62906-1152
US

IV. Provider business mailing address

128 ORANGE ST
ANNA IL
62906-1152
US

V. Phone/Fax

Practice location:
  • Phone: 618-833-8997
  • Fax: 618-833-9091
Mailing address:
  • Phone: 618-833-8997
  • Fax: 618-833-9091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: