Provider Demographics
NPI:1952664559
Name:BASS, MICHAEL RAY (LPC, LMT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAY
Last Name:BASS
Suffix:
Gender:M
Credentials:LPC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27804
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-7804
Mailing Address - Country:US
Mailing Address - Phone:512-502-9556
Mailing Address - Fax:
Practice Address - Street 1:13016 AMARILLO AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78729-7537
Practice Address - Country:US
Practice Address - Phone:512-502-9556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18721101YP2500X
TXMT007325172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No172M00000XOther Service ProvidersMechanotherapist