Healthcare Provider Details

I. General information

NPI: 1992317168
Provider Name (Legal Business Name): LAUREN BAGLEY DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1123 OXFORD CRES NE
BROOKHAVEN GA
30319-1624
US

IV. Provider business mailing address

PO BOX 28528
ATLANTA GA
30358-0528
US

V. Phone/Fax

Practice location:
  • Phone: 404-247-7959
  • Fax: 404-393-2447
Mailing address:
  • Phone: 404-247-7959
  • Fax: 404-393-2447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT014895
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: