Provider Demographics
NPI:1225306210
Name:BASS, ANDREW M (ATC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:M
Last Name:BASS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30118-0001
Mailing Address - Country:US
Mailing Address - Phone:678-839-6628
Mailing Address - Fax:678-839-6546
Practice Address - Street 1:1601 MAPLE STREET ATHLETIC OPERATIONS BUILDING
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30118-0001
Practice Address - Country:US
Practice Address - Phone:678-839-6628
Practice Address - Fax:678-839-6546
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-06
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer