Provider Demographics
NPI:1538704812
Name:BASS, LAURA (LMFT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BASS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6218 VILLAGE 6
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-6918
Mailing Address - Country:US
Mailing Address - Phone:805-844-0995
Mailing Address - Fax:
Practice Address - Street 1:6931 VAN NUYS BLVD STE 310
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3997
Practice Address - Country:US
Practice Address - Phone:080-844-0995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
49043106H00000X
CA49043106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty