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NPI Code Detail

MEDICARE: GAGE WESLEY BASS LCDC

MEDICARE: GAGE WESLEY BASS LCDC
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
1101YA0400XAddiction (Substance Use Disorder) Counselor17807TX

General Provider Information

NPI Number : 1871344812
Entity Type Code : Individual
Provider Name (Legal Business Name) : GAGE WESLEY BASS LCDC
Provider Business Mailing Address
First Line : 505 WASHINGTON ST
Second Line :
City : MCGREGOR
State : TX
Zip : 76657-1641
Country : US
Telephone Number : 254-292-0965
Fax Number :
Provider Business Practice Location Address
First Line : 2220 AUSTIN AVE
Second Line :
City : WACO
State : TX
Zip : 76701-1625
Country : US
Telephone Number : 254-297-8999
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/28/2024
Last Update Date : 06/16/2026

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