Provider Demographics
NPI:1679256028
Name:BASS, RYAN JAKE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:JAKE
Last Name:BASS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:BASS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:1879 MCCOY RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-4823
Mailing Address - Country:US
Mailing Address - Phone:304-528-4620
Mailing Address - Fax:
Practice Address - Street 1:5170 US ROUTE 60
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2004
Practice Address - Country:US
Practice Address - Phone:304-528-4620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-11
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1338103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical