Provider Demographics
NPI:1780980912
Name:SAND R. BAGOON, PH.D., PA
Entity type:Organization
Organization Name:SAND R. BAGOON, PH.D., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAND
Authorized Official - Middle Name:ROYCE
Authorized Official - Last Name:BAGOON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:410-781-7263
Mailing Address - Street 1:1263 GUILFORD RD
Mailing Address - Street 2:
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-8862
Mailing Address - Country:US
Mailing Address - Phone:410-781-7263
Mailing Address - Fax:
Practice Address - Street 1:3355 SAINT JOHNS LN
Practice Address - Street 2:SUITE F
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-2605
Practice Address - Country:US
Practice Address - Phone:410-781-7263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-05
Last Update Date:2011-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02686103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty