Provider Demographics
NPI:1679619738
Name:BAGDWAL, HEATHER REBECCA
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:REBECCA
Last Name:BAGDWAL
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 1:277 SOUTH ST
Mailing Address - Street 2:Y
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-5039
Mailing Address - Country:US
Mailing Address - Phone:805-541-5144
Mailing Address - Fax:805-541-9480
Practice Address - Street 1:277 SOUTH ST
Practice Address - Street 2:Y
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-5039
Practice Address - Country:US
Practice Address - Phone:805-541-5144
Practice Address - Fax:805-541-9480
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator