Provider Demographics
NPI:1588003123
Name:BAGWELL, MARIA INEZ (LCSW, LADAC)
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:INEZ
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:LCSW, LADAC
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:385 CALLE DE ALEGRA STE A
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3423
Mailing Address - Country:US
Mailing Address - Phone:575-526-1105
Mailing Address - Fax:575-524-4266
Practice Address - Street 1:100 W. GRIGGS AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001
Practice Address - Country:US
Practice Address - Phone:575-647-2800
Practice Address - Fax:575-647-2898
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0115311103TA0400X
NMM-08562104100000X
NMC-101081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM52379205Medicaid
NM620292YRNDOtherMEDICARE