Provider Demographics
NPI:1043626864
Name:BAGWELL, MARIA (PT)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15610 WEEPING VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28134-6454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7580 CHARLOTTE HWY STE 500
Practice Address - Street 2:
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-7809
Practice Address - Country:US
Practice Address - Phone:803-548-5662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5380225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist