Provider Demographics
NPI:1023580800
Name:BAGLEY, S. BERNARD (LCSW)
Entity Type:Individual
Prefix:
First Name:S.
Middle Name:BERNARD
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 WINDERMERE CIR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2278
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:148 GEORGIA AVE E STE C
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1616
Practice Address - Country:US
Practice Address - Phone:404-968-4662
Practice Address - Fax:404-968-4562
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0073001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical