Provider Demographics
NPI:1992317168
Name:BAGLEY, LAUREN (DPT)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28528
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30358-0528
Mailing Address - Country:US
Mailing Address - Phone:404-247-7959
Mailing Address - Fax:404-393-2447
Practice Address - Street 1:1123 OXFORD CRES NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-1624
Practice Address - Country:US
Practice Address - Phone:404-247-7959
Practice Address - Fax:404-393-2447
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0148952251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty