Provider Demographics
NPI:1023022415
Name:BAGLEY, SANDRA W (APRN PHD MSW)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:W
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:APRN PHD MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3683 WILDE ROSE LANE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109
Mailing Address - Country:US
Mailing Address - Phone:801-273-0295
Mailing Address - Fax:
Practice Address - Street 1:3683 WILDE ROSE LANE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109
Practice Address - Country:US
Practice Address - Phone:801-273-0295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1166903502104100000X
UT1166904405363LF0000X
UT1166903902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000075209OtherPTAN
UTU000075209OtherPTAN