Provider Demographics
NPI:1053630269
Name:BASS, LESLIE C (MA, LMHC)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:C
Last Name:BASS
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5460 LENA RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211-9500
Mailing Address - Country:US
Mailing Address - Phone:941-907-0525
Mailing Address - Fax:941-462-2968
Practice Address - Street 1:5460 LENA RD
Practice Address - Street 2:SUITE 103
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34211-9500
Practice Address - Country:US
Practice Address - Phone:941-907-0525
Practice Address - Fax:941-462-2968
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 4399101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health