Provider Demographics
NPI:1629807250
Name:BASS, ETHEL ANN (PHD, CADC, CODP1)
Entity type:Individual
Prefix:DR
First Name:ETHEL
Middle Name:ANN
Last Name:BASS
Suffix:
Gender:F
Credentials:PHD, CADC, CODP1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 LINCOLN MALL DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-3821
Mailing Address - Country:US
Mailing Address - Phone:630-499-6197
Mailing Address - Fax:630-423-7873
Practice Address - Street 1:45 W 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-4200
Practice Address - Country:US
Practice Address - Phone:773-995-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2025-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL24935101Y00000X, 101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health