Healthcare Provider Details

I. General information

NPI: 1629894050
Provider Name (Legal Business Name): NANCY JO BAGLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 OLNEY SANDY SPRING RD
SANDY SPRING MD
20860-1005
US

IV. Provider business mailing address

485 HAWKRIDGE LN
SYKESVILLE MD
21784-7637
US

V. Phone/Fax

Practice location:
  • Phone: 443-340-7784
  • Fax:
Mailing address:
  • Phone: 443-340-7784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberCER-114913-F6T1L1
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: