Provider Demographics
NPI:1669015988
Name:BASS, MOLLIE (LMFT)
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:BASS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 N RACINE AVE APT 2SE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-0008
Mailing Address - Country:US
Mailing Address - Phone:206-999-0482
Mailing Address - Fax:
Practice Address - Street 1:915 N RACINE AVE APT 2SE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-0008
Practice Address - Country:US
Practice Address - Phone:206-999-0482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166001498106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist