Provider Demographics
NPI:1912316084
Name:BASS, PHILLIP MICHAEL (MDIV, THM, LCMHC)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:MICHAEL
Last Name:BASS
Suffix:
Gender:M
Credentials:MDIV, THM, LCMHC
Other - Prefix:
Other - First Name:PHILLIP
Other - Middle Name:MICHAEL
Other - Last Name:SHOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MDIV, THM, LPC, NCC
Mailing Address - Street 1:5220 HALLMARK RD STE 403B
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27712-2058
Mailing Address - Country:US
Mailing Address - Phone:919-210-4627
Mailing Address - Fax:
Practice Address - Street 1:1777 FORDHAM BLVD STE 204
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-5885
Practice Address - Country:US
Practice Address - Phone:919-283-3137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA10502101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional