Provider Demographics
NPI:1790250918
Name:BAGLEY, LAKISHA
Entity Type:Individual
Prefix:
First Name:LAKISHA
Middle Name:
Last Name:BAGLEY
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 1:2041 HAMILTON PL
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35215-5841
Mailing Address - Country:US
Mailing Address - Phone:205-218-2055
Mailing Address - Fax:
Practice Address - Street 1:2041 HAMILTON PL
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35215-5841
Practice Address - Country:US
Practice Address - Phone:205-218-2055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-04
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3751G104100000X
AL5306C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker