Provider Demographics
NPI:1407939929
Name:BASS, KELLY JOE (CSWPIP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JOE
Last Name:BASS
Suffix:
Gender:M
Credentials:CSWPIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 E 41ST STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-6047
Mailing Address - Country:US
Mailing Address - Phone:605-357-0121
Mailing Address - Fax:605-357-0190
Practice Address - Street 1:705 E 41ST STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-6047
Practice Address - Country:US
Practice Address - Phone:605-357-0121
Practice Address - Fax:605-357-0190
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCSWPIP1983104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6571380Medicaid
SD6571380Medicaid