Provider Demographics
NPI:1013572916
Name:BASS, DONNA MICHELLE
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:MICHELLE
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 1:1260 E ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4982
Mailing Address - Country:US
Mailing Address - Phone:909-981-2171
Mailing Address - Fax:909-981-2031
Practice Address - Street 1:2180 VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-3325
Practice Address - Country:US
Practice Address - Phone:909-865-2336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1346100419101Y00000X
CA2212229I101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor