Provider Demographics
NPI:1851760813
Name:BASS, EVELYN THERESE (LMT, MED)
Entity Type:Individual
Prefix:MS
First Name:EVELYN
Middle Name:THERESE
Last Name:BASS
Suffix:
Gender:F
Credentials:LMT, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2967 NOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-1952
Mailing Address - Country:US
Mailing Address - Phone:907-957-6459
Mailing Address - Fax:
Practice Address - Street 1:174 S FRANKLIN ST STE 211
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-1362
Practice Address - Country:US
Practice Address - Phone:907-957-6459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-21
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101Y00000X
390200000X
AK101363225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
1912475260OtherEMPLOYER/SUPERVISOR'S NPI