Provider Demographics
NPI:1346741048
Name:BAGNALL, TABITHA (EDS)
Entity Type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:
Last Name:BAGNALL
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 DOUGLAS AVE NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-4611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:750 IMPERIAL ST
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-5309
Practice Address - Country:US
Practice Address - Phone:540-382-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813000654103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0813000654Medicaid