Provider Demographics
NPI:1457671430
Name:BASS, THOMAS WATSON III (LPC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:WATSON
Last Name:BASS
Suffix:III
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 TOWNPARK DR NW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5803
Mailing Address - Country:US
Mailing Address - Phone:404-553-1291
Mailing Address - Fax:
Practice Address - Street 1:125 TOWNPARK DR NW
Practice Address - Street 2:SUITE 300
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5803
Practice Address - Country:US
Practice Address - Phone:404-553-1291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005869101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional