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General NPI Number Information
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NPI Number | 1487666186
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Entity Type | Individual
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Provider Name | WYLIE JAMES BAGLEY PHD
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Gender | Male
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Dates
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Enumeration Date | 08/12/2006
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Last Update Date | 05/24/2021
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Provider Practice Location Address
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Address Line | 3585 HAWVER RD.
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City | SAN ANDREAS
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State | CA
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Zip | 95249
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Country | US
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Telephone | 209-754-1249
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Fax |
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Provider Business Mailing Address
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Address Line | 3055 FLOYD AVE APT J145
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City | MODESTO
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State | CA
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Zip | 95355-7927
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Country | US
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Telephone | 318-791-1555
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 1016
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 122872
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License Number State | CA
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