Provider Demographics
NPI:1780450056
Name:BASHORE, MARISA DAWN (LPC)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:DAWN
Last Name:BASHORE
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 1:9940 CHELATNA CIR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-1477
Mailing Address - Country:US
Mailing Address - Phone:907-302-1070
Mailing Address - Fax:
Practice Address - Street 1:9940 CHELATNA CIR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-1477
Practice Address - Country:US
Practice Address - Phone:907-302-1070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-28
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK163828101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional