=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083454128
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMBER DEANN BASS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2024
-----------------------------------------------------
Last Update Date | 05/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 807 W MAIN ST STE A&B
-----------------------------------------------------
City | TRUMANN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72472-2611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-418-1777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2400 S 48TH ST
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72762-6683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-750-2020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 10455-M
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------