Provider Demographics
NPI:1396868295
Name:BAGLEY, MICHAEL EDWARD (SUDCC 2)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:SUDCC 2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 OAKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95351-4847
Mailing Address - Country:US
Mailing Address - Phone:209-402-0216
Mailing Address - Fax:209-578-1085
Practice Address - Street 1:1028 RENO AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-1127
Practice Address - Country:US
Practice Address - Phone:209-579-1103
Practice Address - Fax:209-578-1085
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-08
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5819101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)