Provider Demographics
NPI:1003577735
Name:BASSETT, KIVA (LAC, MAC)
Entity Type:Individual
Prefix:
First Name:KIVA
Middle Name:
Last Name:BASSETT
Suffix:
Gender:F
Credentials:LAC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34942 CHARLES TOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:VA
Mailing Address - Zip Code:20132-1816
Mailing Address - Country:US
Mailing Address - Phone:240-753-8044
Mailing Address - Fax:
Practice Address - Street 1:13 W POTOMAC ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:MD
Practice Address - Zip Code:21716-1112
Practice Address - Country:US
Practice Address - Phone:240-753-8044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01781171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU01781OtherMARYLAND ACUPUNCTURE LICENSE