Provider Demographics
NPI:1962825505
Name:BASS, MICAH (EXECUTIVE DIRECTOR)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:BASS
Suffix:
Gender:M
Credentials:EXECUTIVE DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16200 BEAR VALLEY RD STE 110
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-8708
Mailing Address - Country:US
Mailing Address - Phone:760-241-1777
Mailing Address - Fax:760-245-2253
Practice Address - Street 1:16200 BEAR VALLEY RD STE 110
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-8708
Practice Address - Country:US
Practice Address - Phone:760-241-1777
Practice Address - Fax:760-245-2253
Is Sole Proprietor?:No
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)