Provider Demographics
NPI:1972897924
Name:BAGNERISE, JOHN FITZGERALD
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:FITZGERALD
Last Name:BAGNERISE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5838 OVERHILL DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-2725
Mailing Address - Country:US
Mailing Address - Phone:323-295-0009
Mailing Address - Fax:323-295-0022
Practice Address - Street 1:5838 OVERHILL DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-2725
Practice Address - Country:US
Practice Address - Phone:323-295-0009
Practice Address - Fax:323-295-0022
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)