Provider Demographics
NPI:1205516101
Name:BAGWELL, BAILEY (BCBA)
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 WHITLOCK SQ SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-3260
Mailing Address - Country:US
Mailing Address - Phone:678-301-0071
Mailing Address - Fax:
Practice Address - Street 1:24 WHITLOCK SQ SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-3260
Practice Address - Country:US
Practice Address - Phone:678-301-0071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA23-2157-435199103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst