Healthcare Provider Details

I. General information

NPI: 1992796486
Provider Name (Legal Business Name): JOHN A. BACON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 SW 6TH ST
CORVALLIS OR
97333-4323
US

IV. Provider business mailing address

525 SW 6TH ST
CORVALLIS OR
97333-4323
US

V. Phone/Fax

Practice location:
  • Phone: 541-752-0834
  • Fax:
Mailing address:
  • Phone: 541-752-0834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW #975
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: