Provider Demographics
NPI:1174195200
Name:BAGWELL, SUSAN BROOKE (LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BROOKE
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12003 FM 346 W
Mailing Address - Street 2:
Mailing Address - City:BULLARD
Mailing Address - State:TX
Mailing Address - Zip Code:75757-8540
Mailing Address - Country:US
Mailing Address - Phone:870-918-8807
Mailing Address - Fax:
Practice Address - Street 1:3800 PALUXY DR STE 240
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1667
Practice Address - Country:US
Practice Address - Phone:903-283-8729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86308101YM0800X
TX86308101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health