Provider Demographics
NPI:1265936108
Name:BASE, PLLC
Entity type:Organization
Organization Name:BASE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:UMBACH
Authorized Official - Last Name:KETTLING
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:704-910-8381
Mailing Address - Street 1:1515 MOCKINGBIRD LN STE 580
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3236
Mailing Address - Country:US
Mailing Address - Phone:704-910-8381
Mailing Address - Fax:704-981-8282
Practice Address - Street 1:1515 MOCKINGBIRD LN STE 580
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3236
Practice Address - Country:US
Practice Address - Phone:704-910-8381
Practice Address - Fax:704-981-8282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-23
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty