MEDICARE: MRS. KATHLEEN MARGARET BASS LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	16270	TX

General Provider Information

NPI Number	:	1003149873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHLEEN MARGARET BASS LPC

Provider Business Mailing Address
First Line	:	3901 KIRBY DR
Second Line	:	#1014
City	:	FORT WORTH
State	:	TX
Zip	:	76155-3939
Country	:	US
Telephone Number	:	817-915-0359
Fax Number	:

Provider Business Practice Location Address
First Line	:	3901 KIRBY DR
Second Line	:	#1014
City	:	FORT WORTH
State	:	TX
Zip	:	76155-3939
Country	:	US
Telephone Number	:	817-915-0359
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2009
Last Update Date	:	09/11/2009

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