| NPI | 1265317523 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KEITH SAMUEL BASS Owner/Provider 618-270-7879 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health |
| Enumeration Date | 2025-08-07 |
| Last Update Date | 2025-08-07 |