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General NPI Number Information
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NPI Number | 1487481735
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Entity Type | Individual
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Provider Name | MICHELLE CASELLA BASS
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Gender | Female
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Dates
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Enumeration Date | 09/18/2024
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Last Update Date | 11/11/2024
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Provider Practice Location Address
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Address Line | 4949 S HILLSDALE AVE
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City | MERIDIAN
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State | ID
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Zip | 83642-7586
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Country | US
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Telephone | 208-706-6400
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Fax | 208-706-6411
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Provider Business Mailing Address
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Address Line | 190 E BANNOCK ST
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City | BOISE
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State | ID
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Zip | 83712-6241
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Country | US
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Telephone |
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Fax |
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 37304
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 8851960
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License Number State | ID
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