Provider Demographics
NPI:1376045005
Name:BAKOVICH, SHANE (LPCC)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:BAKOVICH
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 E WATERLOO RD
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44306-3805
Mailing Address - Country:US
Mailing Address - Phone:234-208-4300
Mailing Address - Fax:330-724-7662
Practice Address - Street 1:1221 E WATERLOO RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44306
Practice Address - Country:US
Practice Address - Phone:234-208-4300
Practice Address - Fax:330-724-7662
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1901061101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0278189Medicaid