Provider Demographics
NPI:1710262563
Name:BAGLEY, KIRSTEN A (LCSW)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:A
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1349 N WILDWOOD ST APT 101
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-5455
Mailing Address - Country:US
Mailing Address - Phone:208-329-0972
Mailing Address - Fax:
Practice Address - Street 1:2273 S VISTA AVE
Practice Address - Street 2:#190
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-7341
Practice Address - Country:US
Practice Address - Phone:208-343-2737
Practice Address - Fax:208-342-3238
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-345541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical