Provider Demographics
NPI:1275944670
Name:BASS, RONNIE
Entity Type:Individual
Prefix:
First Name:RONNIE
Middle Name:
Last Name:BASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 SPECTRUM CIR SE STE 145
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8470
Mailing Address - Country:US
Mailing Address - Phone:678-921-2705
Mailing Address - Fax:
Practice Address - Street 1:1950 SPECTRUM CIR SE STE 145
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8470
Practice Address - Country:US
Practice Address - Phone:678-921-2705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA1950101YM0800X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant