Provider Demographics
NPI:1700932506
Name:BAGLEY, RANDI MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:RANDI
Middle Name:MICHELLE
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 1:7741 S LA ROSA DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-1490
Mailing Address - Country:US
Mailing Address - Phone:480-831-2428
Mailing Address - Fax:
Practice Address - Street 1:8700 S KYRENE RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-2108
Practice Address - Country:US
Practice Address - Phone:480-783-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP5077235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist