Provider Demographics
NPI:1710330824
Name:BAGBY, GENISE RACHELLE (MA, LMHC, CDPT)
Entity Type:Individual
Prefix:
First Name:GENISE
Middle Name:RACHELLE
Last Name:BAGBY
Suffix:
Gender:F
Credentials:MA, LMHC, CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 S GRADY WAY STE 634
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-3218
Mailing Address - Country:US
Mailing Address - Phone:206-679-8291
Mailing Address - Fax:206-274-6252
Practice Address - Street 1:15 S GRADY WAY STE 634
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-3218
Practice Address - Country:US
Practice Address - Phone:206-679-8291
Practice Address - Fax:206-274-6252
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-13
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60705270101YA0400X
WALH60844525101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2099247Medicaid