=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154340784
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT RANDALL BASS PSY.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2006
-----------------------------------------------------
Last Update Date | 03/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 S BARRINGTON AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025-5363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-358-2750
-----------------------------------------------------
Fax | 310-552-0041
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 496 S SPALDING DR
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90212-4104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-358-2750
-----------------------------------------------------
Fax | 310-552-0041
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY18843
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------