Provider Demographics
NPI:1710093380
Name:BASS, ROBERTA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:
Last Name:BASS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 1ST AVE W APT 508
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-6839
Mailing Address - Country:US
Mailing Address - Phone:207-329-6487
Mailing Address - Fax:
Practice Address - Street 1:1600 1ST AVE W APT 508
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-6839
Practice Address - Country:US
Practice Address - Phone:207-329-6487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC0013131041C0700X
FL155441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
003809OtherANTHEM BCBS