Provider Demographics
NPI:1013156215
Name:BASS, ALICE (LCSW, PPS)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:BASS
Suffix:
Gender:F
Credentials:LCSW, PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36420 TORREY PINES DR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-8016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13340 CALIFORNIA ST STE F
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-5169
Practice Address - Country:US
Practice Address - Phone:909-327-6836
Practice Address - Fax:909-316-4443
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS248601041C0700X
CA248601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical