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General NPI Number Information
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NPI Number | 1457423352
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Entity Type | Individual
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Provider Name | CP KELLY BASS PHD
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Gender | Female
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Dates
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Enumeration Date | 11/15/2006
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Last Update Date | 12/05/2012
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Provider Practice Location Address
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Address Line | 1129 E MAIN ST 305
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City | WAILUKU
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State | HI
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Zip | 96793-2053
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Country | US
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Telephone | 808-242-7011
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Fax | 808-244-9010
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Provider Business Mailing Address
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Address Line | 1129 E MAIN ST 305
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City | WAILUKU
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State | HI
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Zip | 96793-2053
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Country | US
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Telephone | 808-242-7011
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Fax | 808-244-9010
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 292
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License Number State | HI
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