Healthcare Provider Details

I. General information

NPI: 1922280668
Provider Name (Legal Business Name): STEPHANIE MICHELLE BASS ATC/R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 12/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-2346
US

IV. Provider business mailing address

2725 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-2346
US

V. Phone/Fax

Practice location:
  • Phone: 573-778-9348
  • Fax: 573-686-4870
Mailing address:
  • Phone: 573-778-9348
  • Fax: 573-686-4870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number117264
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: