MEDICARE: LISA HELLER BASS LMFT

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	106H00000X	Marriage & Family Therapist	KY-0672	KY

General Provider Information

NPI Number	:	1538305636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA HELLER BASS LMFT

Provider Business Mailing Address
First Line	:	2327 LIME KILN LN
Second Line	:	SUITE A
City	:	LOUISVILLE
State	:	KY
Zip	:	40222-3422
Country	:	US
Telephone Number	:	502-296-7754
Fax Number	:	502-339-2820

Provider Business Practice Location Address
First Line	:	2327 LIME KILN LN
Second Line	:	SUITE A
City	:	LOUISVILLE
State	:	KY
Zip	:	40222-3422
Country	:	US
Telephone Number	:	502-296-7754
Fax Number	:	502-339-2820

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

Provider Enumeration Date	:	12/20/2008
Last Update Date	:	12/20/2008

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