Provider Demographics
NPI:1497748578
Name:BASS, MARILYN FAYE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:FAYE
Last Name:BASS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 VILLETTE CT
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-4142
Mailing Address - Country:US
Mailing Address - Phone:636-256-2990
Mailing Address - Fax:636-256-2990
Practice Address - Street 1:802 VILLETTE CT
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-4142
Practice Address - Country:US
Practice Address - Phone:636-256-2990
Practice Address - Fax:636-256-2990
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSW0003411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical