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General NPI Number Information
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NPI Number | 1780980912
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Entity Type | Organization
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Legal Business Name | SAND R. BAGOON, PH.D., PA
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Dates
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Enumeration Date | 02/05/2011
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Last Update Date | 02/05/2011
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Provider Practice Location Address
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Address Line | 3355 SAINT JOHNS LN SUITE F
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City | ELLICOTT CITY
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State | MD
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Zip | 21042-2605
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Country | US
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Telephone | 410-781-7263
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Fax |
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Provider Business Mailing Address
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Address Line | 1263 GUILFORD RD
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City | ELDERSBURG
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State | MD
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Zip | 21784-8862
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Country | US
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Telephone | 410-781-7263
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Fax |
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST
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Name | DR. SAND ROYCE BAGOON
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Credential | PH.D.
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Telephone | 410-781-7263
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 02686
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License Number State | MD
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