Healthcare Provider Details

I. General information

NPI: 1932035292
Provider Name (Legal Business Name): GREGG ROBERT BAGDADE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17235 N 75TH AVE STE G100
GLENDALE AZ
85308-0893
US

IV. Provider business mailing address

17235 N 75TH AVE STE G100
GLENDALE AZ
85308-0893
US

V. Phone/Fax

Practice location:
  • Phone: 602-224-2277
  • Fax: 602-704-2399
Mailing address:
  • Phone: 602-224-2277
  • Fax: 602-704-2399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180016333
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-24301
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: