Provider Demographics
NPI:1679189633
Name:BASH, ALISA RUBY (LMFT)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:RUBY
Last Name:BASH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 ALABAMA ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-2402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:833-964-0134
Practice Address - Street 1:22741 PACIFIC COAST HWY STE 220
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-5097
Practice Address - Country:US
Practice Address - Phone:424-570-1259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47733106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist