Provider Demographics
NPI:1376137018
Name:BASS, DARIC DESHAWN SR (LMT, CPT, CES)
Entity Type:Individual
Prefix:MR
First Name:DARIC
Middle Name:DESHAWN
Last Name:BASS
Suffix:SR
Gender:M
Credentials:LMT, CPT, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 ROSA AVE STE 211
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70005-2831
Mailing Address - Country:US
Mailing Address - Phone:504-355-6550
Mailing Address - Fax:
Practice Address - Street 1:126 BELLEAUWOOD CIRCLE
Practice Address - Street 2:
Practice Address - City:126 BELLEAUWOOD CIRCLE, BELLE CHASSE, LA
Practice Address - State:LA
Practice Address - Zip Code:70037
Practice Address - Country:US
Practice Address - Phone:504-228-9137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA7594225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist