Healthcare Provider Details

I. General information

NPI: 1013409325
Provider Name (Legal Business Name): JUSTIN BASHORE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9988 HIBERT ST STE 102
SAN DIEGO CA
92131-2480
US

IV. Provider business mailing address

4150 INGRAHAM ST APT 3
SAN DIEGO CA
92109-5457
US

V. Phone/Fax

Practice location:
  • Phone: 619-549-0329
  • Fax:
Mailing address:
  • Phone: 989-292-1736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW133623
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: