Healthcare Provider Details

I. General information

NPI: 1487409819
Provider Name (Legal Business Name): ALBERT BAZURTO LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2024
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NE 8TH ST FL 3
GRESHAM OR
97030-7317
US

IV. Provider business mailing address

2156 SE 92ND AVE
PORTLAND OR
97216-2027
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-5558
  • Fax:
Mailing address:
  • Phone: 928-699-8987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC4763
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: