Provider Demographics
NPI:1518370956
Name:BAKAZAN, CORINE (LPC)
Entity Type:Individual
Prefix:MS
First Name:CORINE
Middle Name:
Last Name:BAKAZAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:967 PARK AVE NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2839
Mailing Address - Country:US
Mailing Address - Phone:843-495-6500
Mailing Address - Fax:
Practice Address - Street 1:2926 NE FLANDERS ST STE 3C
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3259
Practice Address - Country:US
Practice Address - Phone:971-270-0167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5501101Y00000X
ORC6632101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor