Provider Demographics
NPI:1578280293
Name:BASS WELLNESS LLC
Entity Type:Organization
Organization Name:BASS WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:NP-P, PMHNP-BC
Authorized Official - Phone:917-575-5662
Mailing Address - Street 1:263 FRANKLIN AVE APT 1B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-3554
Mailing Address - Country:US
Mailing Address - Phone:917-575-5662
Mailing Address - Fax:469-414-5292
Practice Address - Street 1:1180 6TH AVE FL 8
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-8401
Practice Address - Country:US
Practice Address - Phone:917-923-0569
Practice Address - Fax:469-414-5292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty