Provider Demographics
NPI:1043869142
Name:STRADLEY-BASS, LETTIE (LCPC-8478)
Entity Type:Individual
Prefix:
First Name:LETTIE
Middle Name:
Last Name:STRADLEY-BASS
Suffix:
Gender:F
Credentials:LCPC-8478
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9915 N 26TH E
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-6435
Mailing Address - Country:US
Mailing Address - Phone:208-201-4510
Mailing Address - Fax:
Practice Address - Street 1:9915 N 26TH E
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-6435
Practice Address - Country:US
Practice Address - Phone:208-521-8389
Practice Address - Fax:208-271-8882
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID7198101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health