Provider Demographics
NPI:1154805158
Name:BASS, DEBORAH A
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:BASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4279 WATERFRONT CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-3679
Mailing Address - Country:US
Mailing Address - Phone:513-265-5770
Mailing Address - Fax:
Practice Address - Street 1:8559 S MASON MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-9381
Practice Address - Country:US
Practice Address - Phone:513-229-8980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.002149101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty