Provider Demographics
NPI:1497376313
Name:BASS, PHOEBE DIXON
Entity Type:Individual
Prefix:
First Name:PHOEBE
Middle Name:DIXON
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 1:211 S PRIMROSE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-2856
Mailing Address - Country:US
Mailing Address - Phone:909-332-2192
Mailing Address - Fax:
Practice Address - Street 1:211 S PRIMROSE AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-2856
Practice Address - Country:US
Practice Address - Phone:909-332-2192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-01
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7408101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health