Provider Demographics
NPI:1568574234
Name:BASSETT, CYNTHIA JUNE (MA)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:JUNE
Last Name:BASSETT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2585
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49081-2585
Mailing Address - Country:US
Mailing Address - Phone:269-381-0150
Mailing Address - Fax:269-373-4720
Practice Address - Street 1:8036 MOORSBRIDGE ROAD
Practice Address - Street 2:STE 2
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4417
Practice Address - Country:US
Practice Address - Phone:269-327-1438
Practice Address - Fax:269-327-6454
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007154103T00000X
MI6401006422101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI890532OtherBCN PIN
MIOC91042OtherBLUE CROSS BLUE SHIELD
MI045149OtherVALUE OPTIONS
MIOC91042OtherBLUE CROSS BLUE SHIELD