Provider Demographics
NPI:1790452050
Name:BASS, BRADY AUSTIN
Entity Type:Individual
Prefix:
First Name:BRADY
Middle Name:AUSTIN
Last Name:BASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45324 KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:PAISLEY
Mailing Address - State:FL
Mailing Address - Zip Code:32767-9637
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2138 SANDRIDGE CIR
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-4486
Practice Address - Country:US
Practice Address - Phone:352-405-6532
Practice Address - Fax:844-352-7745
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician