Provider Demographics
NPI:1295366433
Name:BASS, MATTHEW BENJAMIN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BENJAMIN
Last Name:BASS
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 THOMAS JOHNSON DR STE 180
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4509
Mailing Address - Country:US
Mailing Address - Phone:301-620-7478
Mailing Address - Fax:
Practice Address - Street 1:81 W FREDERICK ST
Practice Address - Street 2:
Practice Address - City:WALKERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21793-8216
Practice Address - Country:US
Practice Address - Phone:301-910-1025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00008862255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer