Provider Demographics
NPI:1740764182
Name:BASSETT, KATHRYN L (QTT)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:BASSETT
Suffix:
Gender:F
Credentials:QTT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E7475 RAWHIDE RD
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-9025
Mailing Address - Country:US
Mailing Address - Phone:877-300-9101
Mailing Address - Fax:
Practice Address - Street 1:301 N BROADWAY STE 303
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-2557
Practice Address - Country:US
Practice Address - Phone:877-300-9101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI131231-121104100000X
390200000X
WI12121-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program