Provider Demographics
NPI:1801961941
Name:BASS, LESLIE F (MSW)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:F
Last Name:BASS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1083
Mailing Address - Street 2:
Mailing Address - City:EAST ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02474-0020
Mailing Address - Country:US
Mailing Address - Phone:781-662-5118
Mailing Address - Fax:781-835-0005
Practice Address - Street 1:1 CENTRAL ST
Practice Address - Street 2:SUITE 6
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-2023
Practice Address - Country:US
Practice Address - Phone:781-662-5118
Practice Address - Fax:781-835-0005
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1022091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1852264Medicaid
MA1852264Medicaid