Provider Demographics
NPI:1174214076
Name:BAGBY, CLUSSIE
Entity type:Individual
Prefix:MR
First Name:CLUSSIE
Middle Name:
Last Name:BAGBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 S GRADY WAY STE 245
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-3209
Mailing Address - Country:US
Mailing Address - Phone:206-679-8291
Mailing Address - Fax:206-274-6252
Practice Address - Street 1:15 S GRADY WAY STE 245
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-3209
Practice Address - Country:US
Practice Address - Phone:206-679-8291
Practice Address - Fax:206-274-6252
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)