Provider Demographics
NPI:1205410461
Name:BASS, KELLY RENNE' (RBT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RENNE'
Last Name:BASS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MARIGOLD ST
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-4755
Mailing Address - Country:US
Mailing Address - Phone:832-581-8511
Mailing Address - Fax:
Practice Address - Street 1:105 MARIGOLD ST
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-4755
Practice Address - Country:US
Practice Address - Phone:832-581-8511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21166915106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician