Provider Demographics
NPI:1053755959
Name:BASS, KIMBERLY (LPC, CPCS)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BASS
Suffix:
Gender:F
Credentials:LPC, CPCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 BLUE MOUNTAIN LN
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30536-6952
Mailing Address - Country:US
Mailing Address - Phone:122-930-0864
Mailing Address - Fax:
Practice Address - Street 1:71 BLUE MOUNTAIN LN
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30536-6952
Practice Address - Country:US
Practice Address - Phone:122-930-0864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005280101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional