Provider Demographics
NPI:1225113939
Name:BASS, ROBERT (MPT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:BASS
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 DEPOT ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-2601
Mailing Address - Country:US
Mailing Address - Phone:860-274-4092
Mailing Address - Fax:860-274-4099
Practice Address - Street 1:47 VERNON ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3008
Practice Address - Country:US
Practice Address - Phone:203-753-6043
Practice Address - Fax:203-574-3127
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7485225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080007458CT03OtherANTHEM BC BS
CT080007458CT06OtherANTHEM BC BS
CT080007458CT02OtherANTHEM BC BS
CT004247228Medicaid
CT080007458CT04OtherANTHEM BC BS
CT080007485CT01OtherANTHEM BC BS
CT080007458CT05OtherANTHEM BC BS
CT080007458CT02OtherANTHEM BC BS