MEDICARE: JUDI LYNN BAGLEY LMFT

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	106H00000X	Marriage & Family Therapist	MFT13101	CA

General Provider Information

NPI Number	:	1376563866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUDI LYNN BAGLEY LMFT

Provider Business Mailing Address
First Line	:	90 MONTANA DEL LAGO DR
Second Line	:
City	:	RANCHO SANTA MARGARITA
State	:	CA
Zip	:	92688-1366
Country	:	US
Telephone Number	:	949-510-3861
Fax Number	:

Provider Business Practice Location Address
First Line	:	17542 IRVINE BLVD STE F
Second Line	:
City	:	TUSTIN
State	:	CA
Zip	:	92780-3155
Country	:	US
Telephone Number	:	714-508-1919
Fax Number	:	714-508-1935

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

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/08/2007

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