Provider Demographics
NPI:1811410582
Name:BAZINET, ALISSA DYAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALISSA
Middle Name:DYAN
Last Name:BAZINET
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 SE 50TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3024
Mailing Address - Country:US
Mailing Address - Phone:619-203-8403
Mailing Address - Fax:
Practice Address - Street 1:5200 S MACADAM AVE
Practice Address - Street 2:STE 460
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3836
Practice Address - Country:US
Practice Address - Phone:503-272-1713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2719103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical