Healthcare Provider Details

I. General information

NPI: 1710232962
Provider Name (Legal Business Name): NICOLE ANN BASS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 HILLCREST WAY
CRANDALL TX
75114-5140
US

IV. Provider business mailing address

108 HILLCREST WAY
CRANDALL TX
75114-5140
US

V. Phone/Fax

Practice location:
  • Phone: 817-734-6008
  • Fax:
Mailing address:
  • Phone: 817-734-6008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number51094
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: