Provider Demographics
NPI:1336353838
Name:BASS, LIONEL ROSS (FAODP)
Entity Type:Individual
Prefix:MR
First Name:LIONEL
Middle Name:ROSS
Last Name:BASS
Suffix:
Gender:M
Credentials:FAODP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3655 RIVARD ST APT 6
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-2039
Mailing Address - Country:US
Mailing Address - Phone:313-833-0229
Mailing Address - Fax:313-895-0500
Practice Address - Street 1:2081 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-1105
Practice Address - Country:US
Practice Address - Phone:313-895-0500
Practice Address - Fax:313-895-0500
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)