MEDICARE: SUSAN BROOKE BAGWELL LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	86308	TX

General Provider Information

NPI Number	:	1174195200
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN BROOKE BAGWELL LPC

Provider Business Mailing Address
First Line	:	2341 DUELING OAKS DR STE 200
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-0328
Country	:	US
Telephone Number	:	903-258-1675
Fax Number	:

Provider Business Practice Location Address
First Line	:	2341 DUELING OAKS DR STE 200
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-0328
Country	:	US
Telephone Number	:	903-258-1675
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2021
Last Update Date	:	02/13/2026

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Directions to “ SUSAN BROOKE BAGWELL LPC” Practice Location

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