Provider Demographics
NPI:1366013096
Name:BASS, PATRICIA MICHELLE (PLPC)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MICHELLE
Last Name:BASS
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4460 MOUNT ZION RD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65711-2668
Mailing Address - Country:US
Mailing Address - Phone:417-254-4459
Mailing Address - Fax:
Practice Address - Street 1:202 DEAN AVE STE 3
Practice Address - Street 2:
Practice Address - City:AVA
Practice Address - State:MO
Practice Address - Zip Code:65608-5582
Practice Address - Country:US
Practice Address - Phone:417-254-4459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-04
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2021013547101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional