Healthcare Provider Details

I. General information

NPI: 1902194418
Provider Name (Legal Business Name): CYNTINA JONAE BAGLEY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 02/15/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 BUSH RIVER DR
FARMVILLE VA
23901-3179
US

IV. Provider business mailing address

PO DRAWER 248 214 BUSH RIVER DRIVE
FARMVILLE VA
23901
US

V. Phone/Fax

Practice location:
  • Phone: 434-392-3187
  • Fax: 434-392-9221
Mailing address:
  • Phone: 434-392-3187
  • Fax: 434-392-9221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701004977
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: