Provider Demographics
NPI:1851749857
Name:BASS, DEIDRA
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:BASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 NW LAKE WHITNEY PL
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1605
Mailing Address - Country:US
Mailing Address - Phone:772-446-1148
Mailing Address - Fax:
Practice Address - Street 1:525 NW LAKE WHITNEY PL
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1605
Practice Address - Country:US
Practice Address - Phone:772-446-1148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL900341538101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health