Provider Demographics
NPI:1750550844
Name:BASS, LADONNA K (LCAS)
Entity type:Individual
Prefix:MRS
First Name:LADONNA
Middle Name:K
Last Name:BASS
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 GENTLE WINDS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PAULS
Mailing Address - State:NC
Mailing Address - Zip Code:28384-8955
Mailing Address - Country:US
Mailing Address - Phone:910-374-0612
Mailing Address - Fax:
Practice Address - Street 1:1384 LIKHAW ROAD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358
Practice Address - Country:US
Practice Address - Phone:910-737-4004
Practice Address - Fax:910-737-9650
Is Sole Proprietor?:No
Enumeration Date:2008-02-22
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC797101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6111835Medicaid