Provider Demographics
NPI:1992463210
Name:BAGYO, SAMUEL BOBBIO JR (LPC)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:BOBBIO
Last Name:BAGYO
Suffix:JR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 N 1ST ST STE 225
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-3760
Mailing Address - Country:US
Mailing Address - Phone:217-788-4065
Mailing Address - Fax:217-788-4147
Practice Address - Street 1:901 N 1ST ST STE 225
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-3760
Practice Address - Country:US
Practice Address - Phone:217-788-4065
Practice Address - Fax:217-788-4147
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.019860101YP2500X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL820429079OtherBLUECROSS BLUESHIELD
ILXOF820429079OtherBLUECROSS BLUE SHIELD