Provider Demographics
NPI:1558635961
Name:BASS, ROGER FRANK (PHD, BCBA-D)
Entity Type:Individual
Prefix:PROF
First Name:ROGER
Middle Name:FRANK
Last Name:BASS
Suffix:
Gender:M
Credentials:PHD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278 FLORAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711
Mailing Address - Country:US
Mailing Address - Phone:262-853-1951
Mailing Address - Fax:
Practice Address - Street 1:278 FLORANN DRIVE
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711
Practice Address - Country:US
Practice Address - Phone:262-853-1951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1-09-5522OtherBOARD CERTIFIED BEHAVIOR ANALYST