Provider Demographics
NPI:1497074934
Name:BAGNELL, NICHOLAS (PSYD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:BAGNELL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 ELMWOOD AVE STE 300B
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2150
Mailing Address - Country:US
Mailing Address - Phone:803-250-5109
Mailing Address - Fax:
Practice Address - Street 1:1331 ELMWOOD AVE STE 300B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2150
Practice Address - Country:US
Practice Address - Phone:803-250-5109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1548103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical