Provider Demographics
NPI:1083720601
Name:BAGLEY, ROBERT (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:ROB
Other - Middle Name:
Other - Last Name:BAGLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:5662 SHADY FARM LN
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32 W WINCHESTER ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-5607
Practice Address - Country:US
Practice Address - Phone:801-263-6367
Practice Address - Fax:801-263-6370
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6119664-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist