Provider Demographics
NPI:1477811677
Name:BASS, OSHALIQUE
Entity Type:Individual
Prefix:
First Name:OSHALIQUE
Middle Name:
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 1:307 E BENJAMIN HOLT DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-3023
Mailing Address - Country:US
Mailing Address - Phone:209-242-6332
Mailing Address - Fax:
Practice Address - Street 1:1080 MARINA VILLAGE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1078
Practice Address - Country:US
Practice Address - Phone:510-337-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPCCI 2819101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health