Provider Demographics
NPI:1871030817
Name:BAGG, PATRICIA M (CCC-SLP, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:M
Last Name:BAGG
Suffix:
Gender:F
Credentials:CCC-SLP, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11736 SUNRISE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-1444
Mailing Address - Country:US
Mailing Address - Phone:908-216-2593
Mailing Address - Fax:
Practice Address - Street 1:11736 SUNRISE VALLEY DR
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-1444
Practice Address - Country:US
Practice Address - Phone:908-216-2593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000547103K00000X
103K00000X
VA2202007683235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist