Provider Demographics
NPI:1366001281
Name:BAGLEY, FELICIA IRIS
Entity Type:Individual
Prefix:
First Name:FELICIA
Middle Name:IRIS
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1939 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-3836
Mailing Address - Country:US
Mailing Address - Phone:832-492-6488
Mailing Address - Fax:
Practice Address - Street 1:1939 4TH AVE
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-3836
Practice Address - Country:US
Practice Address - Phone:832-492-6488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS113121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty