Provider Demographics
NPI:1063685949
Name:BASS, CHARLES MATTHEW (OT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:MATTHEW
Last Name:BASS
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1742 W BROOKS RD
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48615-9646
Mailing Address - Country:US
Mailing Address - Phone:989-615-6367
Mailing Address - Fax:
Practice Address - Street 1:4421 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-2304
Practice Address - Country:US
Practice Address - Phone:989-832-9026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201005046225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist