Provider Demographics
NPI:1831964410
Name:BAGNONI, STEPHEN MARIO (LCSWA)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MARIO
Last Name:BAGNONI
Suffix:
Gender:
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 EXECUTIVE PARK BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1534
Mailing Address - Country:US
Mailing Address - Phone:336-770-2477
Mailing Address - Fax:
Practice Address - Street 1:250 EXECUTIVE PARK BLVD STE 120
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1534
Practice Address - Country:US
Practice Address - Phone:336-770-2477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-23
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0218421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical