Basic Information
| Provider Information | |||||||||
| NPI: | 1225535800 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASS GORDON | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P. O. BOX 528 | ||||||||
| Address2: | ATTN: OUTPATIENT | ||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9085436100 | ||||||||
| FaxNumber: | 9075436159 | ||||||||
| Practice Location | |||||||||
| Address1: | 829 CHIEF EDDIE HOFFMAN HWY | ||||||||
| Address2: | |||||||||
| City: | BEHTEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995509108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436100 | ||||||||
| FaxNumber: | 9075436159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2018 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1020986 | 05 | AK | MEDICAID |