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General NPI Number Information
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NPI Number | 1639430069
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Entity Type | Individual
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Provider Name | ADAM DAVIS BAGLEY LMFT
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Gender | Male
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Dates
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Enumeration Date | 06/01/2012
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Last Update Date | 06/01/2012
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Provider Practice Location Address
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Address Line | 24 WALESKA ST STE 100
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City | CANTON
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State | GA
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Zip | 30114-2739
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Country | US
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Telephone | 470-253-7252
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 4426
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City | CANTON
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State | GA
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Zip | 30114-0200
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Country | US
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Telephone | 800-397-1710
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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 | MFT001240
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License Number State | GA
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