Provider Demographics
NPI:1205710381
Name:BASORE, OWEN
Entity type:Individual
Prefix:
First Name:OWEN
Middle Name:
Last Name:BASORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 MARIETTA DR
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94127-1846
Mailing Address - Country:US
Mailing Address - Phone:415-914-3453
Mailing Address - Fax:
Practice Address - Street 1:45 S ARROYO PKWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-1930
Practice Address - Country:US
Practice Address - Phone:626-578-5742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-02
Last Update Date:2025-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician