MEDICARE: CARLIN FAE BASS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	08578758	OTHER	CA	KAISER

General Provider Information

NPI Number	:	1295216893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLIN FAE BASS

Provider Business Mailing Address
First Line	:	5616 CAMPANILE WAY
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92115-3707
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5616 CAMPANILE WAY
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92115-3707
Country	:	US
Telephone Number	:	916-832-6576
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2018
Last Update Date	:	08/22/2018

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Directions to “ CARLIN FAE BASS ” Practice Location

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