Provider Demographics
NPI:1306205166
Name:BAGWELL, MELISSA (MA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 W CONVENT ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-6903
Mailing Address - Country:US
Mailing Address - Phone:337-534-0770
Mailing Address - Fax:337-534-4370
Practice Address - Street 1:113 W CONVENT ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501
Practice Address - Country:US
Practice Address - Phone:337-534-0770
Practice Address - Fax:337-534-4370
Is Sole Proprietor?:No
Enumeration Date:2016-02-22
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
TX75242101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health