Provider Demographics
NPI:1134655806
Name:BASS, MONIQUE (LCDC)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:BASS
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 474
Mailing Address - Street 2:
Mailing Address - City:ANGLETON
Mailing Address - State:TX
Mailing Address - Zip Code:77516-0474
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2512 N VELASCO ST
Practice Address - Street 2:
Practice Address - City:ANGLETON
Practice Address - State:TX
Practice Address - Zip Code:77515-3179
Practice Address - Country:US
Practice Address - Phone:855-862-3278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13726101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)