Provider Demographics
NPI:1649751785
Name:BASS, LISA M
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:BASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1563 TAPPAHANNOCK TRL
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-2084
Mailing Address - Country:US
Mailing Address - Phone:404-372-7929
Mailing Address - Fax:
Practice Address - Street 1:3495 PIEDMONT RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-1717
Practice Address - Country:US
Practice Address - Phone:404-372-7929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator