=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427799790
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BASS COMPREHENSIVE WELLNESS CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2022
-----------------------------------------------------
Last Update Date | 04/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 77 FENDLEY TRCE
-----------------------------------------------------
City | NEWNAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30263-7089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-578-5833
-----------------------------------------------------
Fax | 678-578-5830
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 90F GLENDA TRCE STE 344
-----------------------------------------------------
City | NEWNAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30265-3858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-578-5833
-----------------------------------------------------
Fax | 678-578-5830
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/FAMILY NURSE PRACTITIONER
-----------------------------------------------------
Name | ALTHEIA BASS-SELDON
-----------------------------------------------------
Credential | DNP, NP-C
-----------------------------------------------------
Telephone | 678-578-5833
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------