Provider Demographics
NPI:1083925648
Name:BAGWELL, ODILIE (AU D CCC-A)
Entity Type:Individual
Prefix:DR
First Name:ODILIE
Middle Name:
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:AU D CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 STATE ROAD 524
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32926-3560
Mailing Address - Country:US
Mailing Address - Phone:321-504-4327
Mailing Address - Fax:321-504-4387
Practice Address - Street 1:4200 STATE ROAD 524
Practice Address - Street 2:SUITE 103
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32926-3560
Practice Address - Country:US
Practice Address - Phone:321-504-4327
Practice Address - Fax:321-504-4387
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY 989231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist