Provider Demographics
NPI:1730465329
Name:BAGBY, KRISTIN D (MS)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:D
Last Name:BAGBY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 BRYAN VALLEY COMMERCIAL DR.
Mailing Address - Street 2:
Mailing Address - City:OFALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366
Mailing Address - Country:US
Mailing Address - Phone:314-774-1859
Mailing Address - Fax:636-240-8096
Practice Address - Street 1:2120 BRYAN VALLEY COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-3495
Practice Address - Country:US
Practice Address - Phone:314-774-1859
Practice Address - Fax:636-240-8096
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011032194235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist