Provider Demographics
NPI:1609389311
Name:BASS, TIMOTHY JAMES (ATC, LAT, CES)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JAMES
Last Name:BASS
Suffix:
Gender:M
Credentials:ATC, LAT, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 SFH
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84602-2246
Mailing Address - Country:US
Mailing Address - Phone:805-760-8213
Mailing Address - Fax:
Practice Address - Street 1:1143 SFH
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84602-2246
Practice Address - Country:US
Practice Address - Phone:801-422-0974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15602255A2300X
UT6123836-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer