Provider Demographics
NPI:1073643235
Name:BAGLEY, ANGELIQUE (MFT)
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 UNION AVE
Mailing Address - Street 2:SUITE 122
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-3162
Mailing Address - Country:US
Mailing Address - Phone:408-380-3005
Mailing Address - Fax:
Practice Address - Street 1:30 UNION AVE
Practice Address - Street 2:SUITE 122
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-3162
Practice Address - Country:US
Practice Address - Phone:408-380-3005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37081106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist