Basic Information
| Provider Information | |||||||||
| NPI: | 1477811677 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASS | ||||||||
| FirstName: | OSHALIQUE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 E BENJAMIN HOLT DR | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952073023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092426332 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1080 MARINA VILLAGE PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | ALAMEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945011078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103377950 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2012 | ||||||||
| LastUpdateDate: | 07/11/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | PCCI 2819 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.