Provider Demographics
NPI:1164590675
Name:GAVORA, SHARON BAST (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SHARON
Middle Name:BAST
Last Name:GAVORA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14619 NE 82ND AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-1057
Mailing Address - Country:US
Mailing Address - Phone:503-636-4333
Mailing Address - Fax:
Practice Address - Street 1:14619 NE 82ND AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-1057
Practice Address - Country:US
Practice Address - Phone:503-636-4333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1373103TC0700X
WATE00003919103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical