Provider Demographics
NPI:1871284026
Name:BASS, CHANTEL A
Entity type:Individual
Prefix:MRS
First Name:CHANTEL
Middle Name:A
Last Name:BASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3439 LAKE END DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-5809
Mailing Address - Country:US
Mailing Address - Phone:470-304-6067
Mailing Address - Fax:
Practice Address - Street 1:1664 MARKET PLACE BLVD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7927
Practice Address - Country:US
Practice Address - Phone:470-253-4121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABACB922732106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician