Provider Demographics
NPI:1245643964
Name:BASS, RAELYNN L (LPC)
Entity type:Individual
Prefix:MRS
First Name:RAELYNN
Middle Name:L
Last Name:BASS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:881 PONCE DE LEON AVE NE
Mailing Address - Street 2:SUITE #8
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-4252
Mailing Address - Country:US
Mailing Address - Phone:404-808-7919
Mailing Address - Fax:
Practice Address - Street 1:881 PONCE DE LEON AVE NE
Practice Address - Street 2:SUITE #8
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-4252
Practice Address - Country:US
Practice Address - Phone:404-808-7919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008217101YM0800X, 101YA0400X, 106H00000X, 101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor