Provider Demographics
NPI:1174195697
Name:BAGLEY, LACEY (LMFT)
Entity Type:Individual
Prefix:DR
First Name:LACEY
Middle Name:
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 S 400 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-4342
Mailing Address - Country:US
Mailing Address - Phone:509-521-1536
Mailing Address - Fax:
Practice Address - Street 1:363 S 400 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-4342
Practice Address - Country:US
Practice Address - Phone:509-521-1536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT109718443902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT109718443902OtherMARRIAGE & FAMILY THERAPIST