Provider Demographics
NPI:1538607809
Name:BASS, RONESA CALLIE (PTA)
Entity type:Individual
Prefix:MRS
First Name:RONESA
Middle Name:CALLIE
Last Name:BASS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 EXCHANGE DR
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:TX
Mailing Address - Zip Code:76266-8717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1507 EXCHANGE DR
Practice Address - Street 2:
Practice Address - City:SANGER
Practice Address - State:TX
Practice Address - Zip Code:76266-8717
Practice Address - Country:US
Practice Address - Phone:903-780-7476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2120786225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant