Healthcare Provider Details

I. General information

NPI: 1184176422
Provider Name (Legal Business Name): LAURA BASS LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2016
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10630 LITTLE PATUXENT PKWY 209
COLUMBIA MD
21044-3264
US

IV. Provider business mailing address

920 WALNUT WOOD RD
COCKEYSVILLE MD
21030-5407
US

V. Phone/Fax

Practice location:
  • Phone: 410-740-8068
  • Fax:
Mailing address:
  • Phone: 410-370-4868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC4104
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: