Provider Demographics
NPI:1871344812
Name:BASS, GAGE WESLEY
Entity type:Individual
Prefix:
First Name:GAGE
Middle Name:WESLEY
Last Name:BASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2147 LIFESTYLE LN
Mailing Address - Street 2:
Mailing Address - City:MCGREGOR
Mailing Address - State:TX
Mailing Address - Zip Code:76657-3866
Mailing Address - Country:US
Mailing Address - Phone:254-292-0965
Mailing Address - Fax:
Practice Address - Street 1:3015 HERRING AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-3238
Practice Address - Country:US
Practice Address - Phone:888-236-4567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67530101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)