Provider Demographics
NPI:1619320918
Name:BASS, SAMUEL SCOTT (MS, MDIV, LMFT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:SCOTT
Last Name:BASS
Suffix:
Gender:M
Credentials:MS, MDIV, LMFT
Other - Prefix:
Other - First Name:SCOTT
Other - Middle Name:
Other - Last Name:BASS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, MDIV, LMFT
Mailing Address - Street 1:PO BOX 25032
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27611-5032
Mailing Address - Country:US
Mailing Address - Phone:919-760-5430
Mailing Address - Fax:
Practice Address - Street 1:4601 LAKE BOONE TRL
Practice Address - Street 2:SUITE 3B
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7503
Practice Address - Country:US
Practice Address - Phone:919-760-5430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLMFT 1702106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist