Provider Demographics
NPI:1104009166
Name:BAGWELL KUKOR, MARJORIE ANN (PHD)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:ANN
Last Name:BAGWELL KUKOR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARJORIE
Other - Middle Name:BAGWELL
Other - Last Name:KUKOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1130 VESTER AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-7302
Mailing Address - Country:US
Mailing Address - Phone:937-390-3800
Mailing Address - Fax:937-390-3804
Practice Address - Street 1:1130 VESTER AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-7302
Practice Address - Country:US
Practice Address - Phone:937-390-3800
Practice Address - Fax:937-390-3804
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6340103T00000X, 103TC0700X
MOPPY01684103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist