Provider Demographics
NPI:1871776443
Name:BASS, PATRICIA MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MARIE
Last Name:BASS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 JAYNE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2971
Mailing Address - Country:US
Mailing Address - Phone:631-928-6565
Mailing Address - Fax:631-928-6565
Practice Address - Street 1:341 JAYNE BLVD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2971
Practice Address - Country:US
Practice Address - Phone:631-928-6565
Practice Address - Fax:631-928-6565
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR058561-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02068019Medicaid
NYP2069458OtherOXFORD
NYNE3651Medicare PIN