Provider Demographics
NPI:1174280002
Name:BASSHAMDBT LLC
Entity Type:Organization
Organization Name:BASSHAMDBT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BASSHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:248-986-2991
Mailing Address - Street 1:200 ELM ST STE 200D
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6322
Mailing Address - Country:US
Mailing Address - Phone:248-986-2991
Mailing Address - Fax:248-294-1237
Practice Address - Street 1:200 ELM ST STE 200D
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6322
Practice Address - Country:US
Practice Address - Phone:248-986-2991
Practice Address - Fax:248-294-1237
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MYMENTALSPACE.ORG
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-11-28
Last Update Date:2021-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty