Provider Demographics
NPI:1699391573
Name:BAZAN, GUADALUPE V JR (SUDPT)
Entity type:Individual
Prefix:MR
First Name:GUADALUPE
Middle Name:V
Last Name:BAZAN
Suffix:JR
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 W LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-5553
Mailing Address - Country:US
Mailing Address - Phone:509-367-1674
Mailing Address - Fax:
Practice Address - Street 1:609 W LOGAN AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-5553
Practice Address - Country:US
Practice Address - Phone:509-367-1674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60914407101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)