Provider Demographics
NPI:1376672014
Name:MAWLA, BASSAM (DC)
Entity Type:Individual
Prefix:DR
First Name:BASSAM
Middle Name:
Last Name:MAWLA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 CHERRELYN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-2441
Mailing Address - Country:US
Mailing Address - Phone:413-732-7549
Mailing Address - Fax:
Practice Address - Street 1:1145 MAIN ST
Practice Address - Street 2:SUITE 107
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-2143
Practice Address - Country:US
Practice Address - Phone:413-358-0050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3120111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation