Provider Demographics
NPI:1699900779
Name:BAGBY, LISA DANIELLE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DANIELLE
Last Name:BAGBY
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 1:11490 NW TIMBERRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:GRIMES
Mailing Address - State:IA
Mailing Address - Zip Code:50111-8889
Mailing Address - Country:US
Mailing Address - Phone:805-642-7033
Mailing Address - Fax:805-642-7201
Practice Address - Street 1:5810 RALSTON ST FL 2
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6010
Practice Address - Country:US
Practice Address - Phone:805-642-7033
Practice Address - Fax:805-642-7201
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA174400000XOther17-OTHER SERVICES