Provider Demographics
NPI:1518022482
Name:BADCOCK, MARINA (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:BADCOCK
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 SE YAMHILL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-2560
Mailing Address - Country:US
Mailing Address - Phone:503-319-6797
Mailing Address - Fax:
Practice Address - Street 1:1700 NW CIVIC DR
Practice Address - Street 2:SUITE 310
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3770
Practice Address - Country:US
Practice Address - Phone:503-666-8832
Practice Address - Fax:503-669-8641
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2444101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional