Provider Demographics
NPI:1184123507
Name:BASS, NANCY JOHNSON
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:JOHNSON
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 1:7495 B AND A BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3589
Mailing Address - Country:US
Mailing Address - Phone:410-222-1966
Mailing Address - Fax:
Practice Address - Street 1:7495 B AND A BLVD STE 200
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3589
Practice Address - Country:US
Practice Address - Phone:410-222-1966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1368101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional