Provider Demographics
NPI:1699487629
Name:BAGWELL, ABIGAIL ELIZABETH
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:ELIZABETH
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7960 BEREA RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30187-1049
Mailing Address - Country:US
Mailing Address - Phone:678-435-3218
Mailing Address - Fax:
Practice Address - Street 1:3136 GOLF RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1952
Practice Address - Country:US
Practice Address - Phone:877-288-4760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician