Provider Demographics
NPI:1962626275
Name:BASS, LINDSAY ODUM
Entity Type:Individual
Prefix:MRS
First Name:LINDSAY
Middle Name:ODUM
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 1:600 NORTHERN WAY
Mailing Address - Street 2:APARTMENT 1602
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-3800
Mailing Address - Country:US
Mailing Address - Phone:912-398-8891
Mailing Address - Fax:
Practice Address - Street 1:600 NORTHERN WAY
Practice Address - Street 2:APARTMENT 1602
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-3800
Practice Address - Country:US
Practice Address - Phone:912-398-8891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006091235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA352027100AMedicaid