Healthcare Provider Details

I. General information

NPI: 1669541165
Provider Name (Legal Business Name): MARK R. BAGGETT PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2004 MARION ST D PSYCHOLOGICAL APPLICATION. DR.
FORT BRAGG NC
28310-0001
US

IV. Provider business mailing address

2004 MARION ST D PSYCHOLOGICAL APPLICATION. DR.
FORT BRAGG NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 910-432-6833
  • Fax: 910-432-9197
Mailing address:
  • Phone: 910-432-6833
  • Fax: 910-432-9197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number872
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: