Provider Demographics
NPI:1245772011
Name:BASS, CHLOE
Entity Type:Individual
Prefix:
First Name:CHLOE
Middle Name:
Last Name:BASS
Suffix:
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:PO BOX 333
Mailing Address - Street 2:
Mailing Address - City:WARD
Mailing Address - State:AR
Mailing Address - Zip Code:72176-0333
Mailing Address - Country:US
Mailing Address - Phone:501-588-3211
Mailing Address - Fax:501-353-2599
Practice Address - Street 1:1500 WILSON LOOP
Practice Address - Street 2:
Practice Address - City:WARD
Practice Address - State:AR
Practice Address - Zip Code:72176-8656
Practice Address - Country:US
Practice Address - Phone:501-588-3211
Practice Address - Fax:501-353-2599
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-10
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT4245225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR217101721Medicaid