=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467142620
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. BASSIE SOMBIE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2023
-----------------------------------------------------
Last Update Date | 05/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1653 LITITZ PIKE STE 2130
-----------------------------------------------------
City | LANCASTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17601-6507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-990-2323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8723 W CHESTER PIKE APT D6
-----------------------------------------------------
City | UPPER DARBY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19082-1113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-396-7119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | BH006194
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------