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General NPI Number Information
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NPI Number | 1952664559
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Entity Type | Individual
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Provider Name | MICHAEL RAY BASS LPC, LMT
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Gender | Male
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Dates
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Enumeration Date | 06/19/2012
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Last Update Date | 06/19/2012
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Provider Practice Location Address
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Address Line | 13016 AMARILLO AVE
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City | AUSTIN
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State | TX
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Zip | 78729-7537
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Country | US
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Telephone | 512-502-9556
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 27804
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City | AUSTIN
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State | TX
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Zip | 78755-7804
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Country | US
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Telephone | 512-502-9556
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 18721
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 172M00000X
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Taxonomy Name | Mechanotherapist
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License Number | MT007325
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License Number State | TX
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