Provider Demographics
NPI:1366455909
Name:BASS, NANCY CAROLE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:CAROLE
Last Name:BASS
Suffix:
Gender:F
Credentials:CCC-SLP
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 975
Mailing Address - Street 2:
Mailing Address - City:WESSON
Mailing Address - State:MS
Mailing Address - Zip Code:39191-0975
Mailing Address - Country:US
Mailing Address - Phone:601-643-0153
Mailing Address - Fax:601-833-0080
Practice Address - Street 1:20 THE RAYS TRL SE
Practice Address - Street 2:
Practice Address - City:BOGUE CHITTO
Practice Address - State:MS
Practice Address - Zip Code:39629-8500
Practice Address - Country:US
Practice Address - Phone:601-833-8363
Practice Address - Fax:601-833-0080
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2198235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0126674Medicaid