Provider Demographics
NPI:1710923180
Name:BAGBY, MARY M (LPC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:M
Last Name:BAGBY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6103 LORCOM CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-1320
Mailing Address - Country:US
Mailing Address - Phone:703-569-8518
Mailing Address - Fax:
Practice Address - Street 1:6103 LORCOM CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-1320
Practice Address - Country:US
Practice Address - Phone:703-569-8518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002092101YP2500X
MDLCO971101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional