Healthcare Provider Details

I. General information

NPI: 1801286000
Provider Name (Legal Business Name): STACEY BASS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8801 J M KEYNES DR STE 325
CHARLOTTE NC
28262-8613
US

IV. Provider business mailing address

3851 DUNHAGAN RD STE 102
GREENVILLE NC
27858-6640
US

V. Phone/Fax

Practice location:
  • Phone: 252-751-0518
  • Fax:
Mailing address:
  • Phone: 252-751-0518
  • Fax: 252-565-4505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-14-16998
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: