Provider Demographics
NPI:1326422429
Name:BASS, TABITHA
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:BASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TABITHA
Other - Middle Name:RUTH
Other - Last Name:LAVERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4531 SE BELMONT ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1675
Mailing Address - Country:US
Mailing Address - Phone:503-215-6556
Mailing Address - Fax:
Practice Address - Street 1:17727 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-4803
Practice Address - Country:US
Practice Address - Phone:503-215-9800
Practice Address - Fax:503-215-9810
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker