Provider Demographics
NPI:1902110349
Name:BAGGETT, CHARLEIGH (PTA)
Entity type:Individual
Prefix:
First Name:CHARLEIGH
Middle Name:
Last Name:BAGGETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5348 OLD JACKSONVILLE HWY
Mailing Address - Street 2:APT 314
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3350
Mailing Address - Country:US
Mailing Address - Phone:817-433-0721
Mailing Address - Fax:
Practice Address - Street 1:4801 TROUP HWY
Practice Address - Street 2:SUITE 800
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-2356
Practice Address - Country:US
Practice Address - Phone:903-939-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2075100225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX149984001Medicaid
TX676535Medicare UPIN