Provider Demographics
NPI:1366849713
Name:BAGWELL, STEVEN MICHAEL (DPT)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:MICHAEL
Last Name:BAGWELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2285 ROSE AVE APT C
Mailing Address - Street 2:
Mailing Address - City:SIGNAL HILL
Mailing Address - State:CA
Mailing Address - Zip Code:90755-3724
Mailing Address - Country:US
Mailing Address - Phone:909-938-0719
Mailing Address - Fax:
Practice Address - Street 1:1027 N HARBOR BLVD STE B
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1310
Practice Address - Country:US
Practice Address - Phone:714-870-8478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41946225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist