Healthcare Provider Details

I. General information

NPI: 1104227313
Provider Name (Legal Business Name): SANDRA HUNTER BASS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2014
Last Update Date: 11/02/2024
Certification Date: 11/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8407 S CONSTANCE AVE
CHICAGO IL
60617-2218
US

IV. Provider business mailing address

8407 S CONSTANCE AVE
CHICAGO IL
60617-2218
US

V. Phone/Fax

Practice location:
  • Phone: 773-656-4358
  • Fax:
Mailing address:
  • Phone: 773-656-4358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.017928
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34007290A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: