Basic Information
Provider Information
NPI: 1003000910
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BASS
FirstName: MARTHA
MiddleName: BROWNSTEIN
NamePrefix: MS.
NameSuffix:  
Credential: LICSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 16 WAYLAND HILLS RD
Address2:  
City: WAYLAND
State: MA
PostalCode: 017783810
CountryCode: US
TelephoneNumber: 5086530451
FaxNumber: 5086536094
Practice Location
Address1: 16 WAYLAND HILLS RD
Address2:  
City: WAYLAND
State: MA
PostalCode: 017783810
CountryCode: US
TelephoneNumber: 5086530451
FaxNumber: 5086536094
Other Information
ProviderEnumerationDate: 09/04/2007
LastUpdateDate: 09/04/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700X1022489MAY Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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