Healthcare Provider Details

I. General information

NPI: 1104259860
Provider Name (Legal Business Name): ANDREW R BAGLEY MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2013
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 N MAYFAIR RD
WAUWATOSA WI
53226-3432
US

IV. Provider business mailing address

541 MEADOW BREEZE LN
GRAFTON WI
53024-2513
US

V. Phone/Fax

Practice location:
  • Phone: 414-737-2300
  • Fax:
Mailing address:
  • Phone: 414-737-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8506-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: