Healthcare Provider Details

I. General information

NPI: 1952362279
Provider Name (Legal Business Name): JOANNE S BAGBY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1606 PHYSICIANS DR SUITE 103
WILMINGTON NC
28401-7348
US

IV. Provider business mailing address

1333 GRANDIFLORA DR
LELAND NC
28451-9527
US

V. Phone/Fax

Practice location:
  • Phone: 910-362-8811
  • Fax:
Mailing address:
  • Phone: 910-383-2789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR031021-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: