Provider Demographics
NPI:1295623189
Name:BASS, MAKAYLA MICHELLE
Entity type:Individual
Prefix:MS
First Name:MAKAYLA
Middle Name:MICHELLE
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 1:2440 FAIRBURN RD SW STE 101
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5253
Mailing Address - Country:US
Mailing Address - Phone:470-419-8842
Mailing Address - Fax:470-419-8442
Practice Address - Street 1:2440 FAIRBURN RD SW STE 101
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5253
Practice Address - Country:US
Practice Address - Phone:470-419-8842
Practice Address - Fax:470-419-8442
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-27
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-25-413143106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician