Provider Demographics
NPI:1609250489
Name:BAGLEY, KIMBERLY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:TACZAK
Other - Last Name:BAGLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:PO BOX 1781
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33831-1781
Mailing Address - Country:US
Mailing Address - Phone:321-961-3489
Mailing Address - Fax:
Practice Address - Street 1:365 LYLE PKWY
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-9247
Practice Address - Country:US
Practice Address - Phone:863-397-3315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-12
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist