Provider Demographics
NPI:1184825499
Name:BASS, CRISTY LEA II
Entity Type:Individual
Prefix:MRS
First Name:CRISTY
Middle Name:LEA
Last Name:BASS
Suffix:II
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-1410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4455 NE HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333
Practice Address - Country:US
Practice Address - Phone:541-451-4919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5295680104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker