Healthcare Provider Details

I. General information

NPI: 1710262563
Provider Name (Legal Business Name): KIRSTEN A BAGLEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 08/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2273 S VISTA AVE #190
BOISE ID
83705-7341
US

IV. Provider business mailing address

1349 N WILDWOOD ST APT 101
BOISE ID
83713-5455
US

V. Phone/Fax

Practice location:
  • Phone: 208-343-2737
  • Fax: 208-342-3238
Mailing address:
  • Phone: 208-329-0972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-34554
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: