Provider Demographics
NPI:1073982658
Name:BASSAREAR, JOSHUA (PLMSW)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:BASSAREAR
Suffix:
Gender:M
Credentials:PLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 N LETITIA AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701
Mailing Address - Country:US
Mailing Address - Phone:603-831-3413
Mailing Address - Fax:
Practice Address - Street 1:4253 N CROSSOVER RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4593
Practice Address - Country:US
Practice Address - Phone:479-443-6496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1073982658Medicaid