Basic Information
| Provider Information | |||||||||
| NPI: | 1790981561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1838 | ||||||||
| Address2: | |||||||||
| City: | ALIEF | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774111838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8328949359 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 896 ROBIN RANCH RD | ||||||||
| Address2: | |||||||||
| City: | LOCKHART | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786444578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123762101 | ||||||||
| FaxNumber: | 5123983040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 05/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | 13495 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 77327 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 77327 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 4173981-02 | 05 | TX | MEDICAID | 4173981-01 | 05 | TX | MEDICAID |