Healthcare Provider Details

I. General information

NPI: 1497357420
Provider Name (Legal Business Name): MONIKA LASHELLE BASS AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2020
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3340 KEMPER ST STE 105
SAN DIEGO CA
92110-4907
US

IV. Provider business mailing address

3340 KEMPER ST STE 105
SAN DIEGO CA
92110-4907
US

V. Phone/Fax

Practice location:
  • Phone: 619-523-8121
  • Fax:
Mailing address:
  • Phone: 619-523-8121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAMFT116920
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: