Provider Demographics
NPI:1396386025
Name:BASS, MANDY (MA, LPC, NCC)
Entity Type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:
Last Name:BASS
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17000 OLD WESTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MOSELEY
Mailing Address - State:VA
Mailing Address - Zip Code:23120-2340
Mailing Address - Country:US
Mailing Address - Phone:434-962-9730
Mailing Address - Fax:
Practice Address - Street 1:14411 JUSTICE RD STE B
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-6907
Practice Address - Country:US
Practice Address - Phone:434-962-9730
Practice Address - Fax:276-597-5158
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008636101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA601448936Medicaid