Basic Information
| Provider Information | |||||||||
| NPI: | 1942706106 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASS | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | JACKSON | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16026 NE SANDY BLVD APT 130 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972308810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604499685 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12901 SE 97TH AVE STE 180 | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970157903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712066337 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2018 | ||||||||
| LastUpdateDate: | 04/04/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | OR | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.