Basic Information
| Provider Information | |||||||||
| NPI: | 1619261237 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASS | ||||||||
| FirstName: | CASSAUNDRA | ||||||||
| MiddleName: | EILENE | ||||||||
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| Credential: | LCAS, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 208 ECHO RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | SWANSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285848548 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 208 ECHO RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | SWANSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285848548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9999999999 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2011 | ||||||||
| LastUpdateDate: | 07/22/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 11/17/2011 | ||||||||
| NPIReactivationDate: | 07/22/2014 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCAS #1730 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | LPC-A #A7997 | NC | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.