Provider Demographics
NPI:1679212906
Name:BAGMON MCIVER, LASHAUNDRA DIANNE
Entity Type:Individual
Prefix:MRS
First Name:LASHAUNDRA
Middle Name:DIANNE
Last Name:BAGMON MCIVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8540 BAYCENTER RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7420
Mailing Address - Country:US
Mailing Address - Phone:904-448-1933
Mailing Address - Fax:
Practice Address - Street 1:8540 BAYCENTER RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7420
Practice Address - Country:US
Practice Address - Phone:904-448-1933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT3565106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist