MEDICARE: KATHLEEN T. BAGBY LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904001807	VA

General Provider Information

NPI Number	:	1033142179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN T. BAGBY LCSW

Provider Business Mailing Address
First Line	:	133 27TH ST SE
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24014-3307
Country	:	US
Telephone Number	:	540-343-3389
Fax Number	:

Provider Business Practice Location Address
First Line	:	4220 CYPRESS PARK DR
Second Line	:	SUITE B
City	:	ROANOKE
State	:	VA
Zip	:	24018-8440
Country	:	US
Telephone Number	:	540-772-1872
Fax Number	:	540-772-4830

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	07/08/2007

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