Provider Demographics
NPI:1841594983
Name:BAGWELL, MARY LEE (MA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LEE
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 E MYRTLE AVE
Mailing Address - Street 2:SUITE 504
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-8600
Mailing Address - Country:US
Mailing Address - Phone:423-928-2885
Mailing Address - Fax:423-928-2885
Practice Address - Street 1:112 E MYRTLE AVE,
Practice Address - Street 2:SUITE 504
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-8600
Practice Address - Country:US
Practice Address - Phone:423-928-2885
Practice Address - Fax:423-928-2885
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNA0000000041237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter