Provider Demographics
NPI:1457423352
Name:BASS, CP KELLY (PHD)
Entity Type:Individual
Prefix:DR
First Name:CP
Middle Name:KELLY
Last Name:BASS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 E MAIN ST
Mailing Address - Street 2:305
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-2053
Mailing Address - Country:US
Mailing Address - Phone:808-242-7011
Mailing Address - Fax:808-244-9010
Practice Address - Street 1:1129 E MAIN ST
Practice Address - Street 2:305
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-2053
Practice Address - Country:US
Practice Address - Phone:808-242-7011
Practice Address - Fax:808-244-9010
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI292103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI000077OtherHMAA
HI01542101Medicaid
HIH0000TCBHBOtherMEDICARE PTAN
HIH0000TCBHBOtherMEDICARE PTAN